
Glass. 
Book. 



COPYRIGHT DEPOSIT 



THE 

IRRIGATION TREATMENT 



OF 



GONORRHOEA 



ITS 



LOCAL COMPLICATIONS AND 8EQUELE 



BY 

FEED. C. VALENTINE, M.D. 

professor of genito-drlnary diseases, new york school of clinical medicine: 
Genito-Urinary Surgeon, West Side German Dispensary; Genito- 
urinary Consultant to the United Hebrew Charities 
to the Metropolitan Hospital and 
dispensary, etc., etc. 



ILLUSTRATED BY FIFTY-SEVEN ENGRAVINGS 



NEW YORK 
WILLIAM WOOD AND COMPANY 

MDCCCC 



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MAP 1 S 1900 

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Copyright, 1900 
By WILLIAM WOOD AND COMPANY 



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rpiIE GENERAL PRACTITIONER, more particularly he who labors in 
■*- the smaller communities, must be a specialist in all branches of medicine. 
The demands upon his waking and sleeping hours are usually so great that 
time is not his for extensive literary research or for the study of exhaustive 
theoretical volumes. 

Herein lies the motive for the present effort of the writer to offer as con- 
cisely as possible the essential facts in connection with the treatment of gonor- 
rhoea, and to place before the busy practitioner the results of his experience. 

The General Practitioner, who conscientiously exercises his power to 
benefit mankind, must treat gonorrhoea when called upon to do so ; and he 
must treat it in a manner that will protect his patients and the public from 
the consequences of this disease. Furthermore, it is the work of the General 
Practitioner which forms the firm foundation upon which the superstructure 
of medical specialism is built ; therefore, 

TO 
THE GENERAL PRACTITIONER 

THIS LITTLE BOOK 
IS FRATERNALLY DEDICATED 



INTRODUCTION. 



The larger and better works on genito-urinary diseases fully 
discuss gonorrhoea. Unfortunately none of them, except the 
master-work of Guy on, ' makes much more than casual mention 
of the irrigation treatment of this ever-prevalent, painful dis- 
ease, which when empirically treated is likely to be fraught 
with most disastrous consequences. 

It is the purpose of this little book to fill the hiatus, until 
abler pens supply the missing chapter in new editions of their 
works. 

1 Guyon : Lecons cliniques sur les Maladies des Voies urinaires, troisieme 
Edition. Paris, 1894. 



THE IRRIGATION TREATMENT OF 
GONORRHCEA. 



GENERAL CONSIDERATIONS. 

Goldberg 1 was the first to subject the results of the irriga- 
tion treatment of gonorrhoea to mathematical tests. He summed 
up the publications of all who had written favorably or other- 
wise on the method, and showed that these reported : 

60 per cent, of acute gonorrhoeas cured within 10 days, 
30 " " " " " " " 14 days, 

10 " " " " " were not cured. 

Of the last mentioned — one-tenth of the cases — the failure was 
clearly attributable in one-half of them to indulgence in alcohol 
and coitus, and the remaining 1iyq per cent, were not explained. 
These failures in the hands of such authors will probably find 
their explanation in those rapid invasions of the urethral adnexa 
which will be considered later on in discussing the complications 
of gonorrhoea. 

At all events, no method of treating gonorrhoea offers as many 
scientific grounds for its employment, and not another can show 
ninety per cent, of cases cured within fourteen days. 

That a large number in the profession appreciate this is 
shown by the following facts : 

In 1894 not a dozen men in the world were using the irriga- 
tion treatment in gonorrhoea. Many had attempted and dis- 
carded it, owing to defective apparatus; others had obtained 
negative or unfortunate results, owing to faulty technique. In 
face of the adverse criticisms these conditions provoked, it 

1 Goldberg: "Die Behandlung der Gonorrhoe mit Ausspiilungen von uber- 
mangansaurem Kali." Centralblatt fur die Krankheiten der Harn- und Sexual- 
Organe, Band vii., Hefte 3 und 4. 
1 



2 THE IRRIGATION TREATMENT OF GONORRHOEA. 

required commendable courage on the part of Felicke of Buda- 
pest, Janet of Paris, E. R. W. Frank of Berlin, and Swin- 
burne of New York to persist in a method in which then, they 
alone succeeded. 

Some time before, I was convinced of the results obtainable 
and of the opportunities offered for advancing gonorrhoea from 
its empiric therapeutic chaos. It seemed to me that if the pro- 
fession at large were offered an apparatus by which irrigations 
might be easily and correctly performed, the advantage to 
science and to patients would be more readily appreciable. 
There is no purpose in reciting the evolution of the apparatus. 
It will suffice to describe herein the last result of six modifica- 
tions, the one now used. 

The middle of 1899 shows about six thousand physicians in 
the United States alone, using the irrigation method, errone- 
ously called the "Valentine method," of treating gonorrhoea. 
I did nothing except devise a simple apparatus, develop the 
technique, modify the medications, render the rules precise, 
and write many articles, carefully weighing the advantages and 
avoidable disadvantages of the irrigation treatment. 



I. THE IRRIGATOR. 

This apparatus consists of a board (Pig. 1, a a) with a brass 
rod attached (g). Readily sliding upon the brass rod is a metal 
block, connected by a strong bar to a collar (c). This firmly 
holds a percolator (h) of a capacity of 1,000 c.c. (about one 
quart). The opening that interrupts the completeness of the 
collar permits easy removal of the percolator when required. 
The nipple of the percolator is inserted into a soft-rubber tube 
(i) seven feet long. The distal end of this rubber tube is 
passed through a stopcock, whose essential parts are a ring (J) 
for admission of the fourth finger ; a sliding flange (k) to increase 
or decrease the pressure of the fluid; a shield (?) to catch the 
fluid that spurts from the urethra and divert it into a basin held 
by the patient ; a small ring (ra) to suspend the stopcock when 
not in use. Pig. 1 shows a urethral nozzle (n) inserted into the 
rubber tube, projecting through the stopcock. 

The board has brass plates above and below perforated for 



THE IRRIGATOR. 



screws, by means of which the apparatus is attached to the wall. 

At/, in Fig. 1, a hook attached to the lower end of the board is 

shown. This hook holds a ring at the end of a stout cord. 

The cord passes over a pulley 

(d) and is fastened to the 

travelling block mentioned 

before. 

The variations of pressure 
required for anterior and in- 
travesical irrigations are ac- 
complished by the action of 
the right thumb and index 
finger on the stopcock, and 
not by variations in the height 
of the percolator. Its eleva- 
tion is always the same; it 
is lowered only for the pur- 
pose of filling or cleaning. 

Reference to Fig. 1 shows 
too clearly to merit further 
study, the manner in which 
the parts of the apparatus 
are put together. 

Experience has demon- 
strated that when the top of 
the irrigator board is attached 
to the wall at an elevation of 
nine feet from the floor, suffi- 
cient pressure is obtained 
for all purposes. With in- 
creasing experience the phy- 
sician finds that seven and 
one-half feet elevation suffices. 

It will be found conven- 
ient to devote a little study to the stopcock and nozzles, de- 
spite their simplicity. 

If the stopcock is taken in the right hand, and the fourth 
(ring) finger passed through the large ring on the metal tube, 
the thumb and index finger will easily reach and control the 
flange. On pushing it forward it compresses the clips, narrow- 




Fig. 1.— Author's Urethral 
Irrigator. 



Intravesical 



THE IRRIGATION TREATMENT OF GONORRHCEA. 




Fig. 2.— Author's Stopcock. 



ing or even closing the lumen of the rubber tube ; on drawing it 
back, the rubber tube resumes its entire calibre. One or two 
efforts will teach the physician to allow single drops to escape 

from the nozzle. By 
gradually drawing back 
the flange the stream is 
increased until a strong 
jet carries over six feet. 
All variations in the 
flow, from mere drops 
to strong jet, are accom- 
plished with the percolator raised to its greatest height, nine 
feet from the floor. The value of so controlling the flow by 
slight contraction of the thumb and index linger will become 
more evident on considering the technique of irrigations. 

The nozzles are of glass that can be easily sterilized. Their 
shapes are shown in Fig. 3. A is a pointed nozzle, for irrigat- 
ing a normal meatus. It is important that the irrigating fluid 
have as easy exit as it has entrance into the urethra. The 
point of this nozzle allows 



Nozzle A for normal meatus. 



Nozzle B for large meatus. 



}„■■■ 



D 



Nozzle C for small meatus. 



washing the entire ure- 
thra and the meatus as 
well. 

B is a dome-shaped 
nozzle devised to accom- 
plish anterior and pos- 
terior irrigations without 
changing the nozzle, 
when a meatus is congen- 
ially very large or has 
been made so by 
meatotomy. 

G is a blunt 
nozzle for use 
when a congen- 
itally very small 

(pin-point) meatus would otherwise prevent irrigation, or when 
the normal meatus is so swollen as to prevent the introduction 
of nozzle A. Its orifice then is merely pressed against the 
meatus and the stream so directed through it into the urethra. 




Nozzle D for female urethra. 



Fig. 3.— Glass Nozzles. 



THE IRRIGATOR. 5 

D is devised for irrigations of the female urethra and bladder. 
Its shape is the same as nozzle A ; its length, however, is three 
times greater. The reason for its increased length lies in the 
fact that all females must be irrigated in the recumbent posture, 
and for the protection of the thighs from soiling with the irri- 
gating fluid as well as for self-evident anatomical reason, the 
shield must be brought down between the thighs. If the nozzle 
were as short as the others, the shield would prevent it coming 
into contact with the meatus. 

Attachment of Nozzles. — The nozzle appropriate for the size 
of meatus being selected with sterilized fingers, its tubular end 
is easily inserted into the rubber tube projecting through the 




Fig. 4.— Manner of Attaching a Nozzle. 

stopcock. After the tubular end of the nozzle is firmly inserted, 
the rubber tube should be drawn backward until the shoulder of 
the nozzle is arrested by the metal projection of the stopcock. 
This then holds the nozzle firmly, making it practically one 
piece with the stopcock. 

As this book may fall into the hands of one or another prac- 
titioner not especially so endowed that he readily grasps me- 
chanical ideas, I have thought well to be explicit, even to verbos- 
ity, in the above directions for use of the stopcock and nozzles. 

Another form of this irrigator was modified from suggestions 
submitted to me by M. Wocher & Son, of Cincinnati. The illus- 
tration shows that in this apparatus a metal bracket takes the 
place of the board previously described. The rubber tube ex- 
panded and reinforced will not slip out of the stopcock, and 
therefore requires no nozzle or closing of the clips to retain it. 
A supplementary bracket (s) receives and holds the percolator 
when it is let down to be filled. The graceful form of this irri- 
gating apparatus appeals to many practitioners, especially those 
to whom economy in oflfice space is an object. 

Care of the Irrigator. — Despite the simplicity of the apparatus 



THE IRRIGATION TREATMENT OF GONORRHOEA. 




it, like any other, would not only become unsightly, but its util- 
ity destroyed by uncleanli- 
ness. 

To preserve the apparatus 
and to have it always ready 
for work, it will be well to ob- 
serve the following rules : 

1. When not in use, keep 
the flange of the stopcock 

m well drawn back, so as to 
have no compression whatever 
of the rubber tube. 

2. When the first described 
form of irrigator is used, keep 
a clean nozzle inserted in the 
rubber tube to prevent the 
tube slipping out of the stop- 
cock. Its shoulder will hold 
the rubber tube in place. With 
the bracket irrigator, as men- 
tioned above, this precaution 
is not necessary. 

3. To prevent the formation 
of angles in the rubber tube, 
which would eventually cause 
it to break, and to reduce the 
strain upon the part of the tube 
into which the percolator's 
nipple is inserted, hang the 
stopcock mounted as above 
described, by its small ring 
upon a cup-hook conveniently 
placed for the purpose. 

4. Thoroughly wash the ir- 
rigator each time after it has 

been used. Ordinarily it will suffice to let hot water run through 
it several times. Although the percolator may not be visibly 
stained, it should be remembered that permanganate of potassium 
tends quickly to destroy the rubber tube. It will be preserved 
almost indefinitely if this rule is observed. 




Fig. 5.— Modified Bracket Irrigator. 



THE IRRIGATOR. 7 

5. Should the percolator become soiled, let a strong solution 
of oxalic acid run through it. If this does not suffice, use the 
oxalic solution on cotton mops to rub out the stains. Fill the 
percolator at least three times with clean hot water after using 
oxalic acid, lest some remain and be accidentally injected into 
the urethra or bladder. 

6. After each use wash all parts of the shield with soap and 
hot water, rub it with cotton soaked in bichloride 1 : 1,000, dry 
it and hang upon its hook. This precaution will prevent the 
possible carrying of infection to another patient. While it is 
true that the majority of cases irrigated have gonorrhoea, there 




Fig. 6.— Manner of Suspending Stopcock. 



is no reason for the physician to expose them to new infection. 
On the other hand, many patients needing irrigations are not 
gonorrhceal, as, for example, cases requiring urethral or vesical 
instrumentation or cases of contracted bladder. They certainly 
should not be exposed to gonorrhceal infection which can be 
avoided by the simple precautions of cleanliness. 

7. It would be criminal negligence to subject any patient to 
the danger of infection by using a nozzle that has been employed 
in the previous case. This danger is easily avoided by the fol- 
lowing steps : 

(a) Immediately after irrigation hold the shield with the 
used nozzle still in place, under boiling, running water. 

(b) Eemove the nozzle and place it into a strong bichloride 
solution, kept ready in a glass dish for that purpose. 

(c) When the day's office work is done, boil all the used 
nozzles for ten minutes in strong caustic soda solution. 



8 THE IRRIGATION TREATMENT OF GONORRHOEA. 

(d) After boiling, place the nozzles in a strong (1:1,000) 
bichloride solution, kept in a covered glass or china dish re- 
served for sterilized nozzles. 

(e) Rinse each nozzle again in clean hot water before using. 

(/) While the steps described in a to e suffice for the steril- 
ization of nozzles, it is not amiss to take extra precautions when 
a syphilitic has been irrigated. In a large practice where many 
nozzles are used, it is well to break the nozzle after employing 
it on a case with lues. If economy prompts keeping such noz- 
zles, each one should be boiled separately and kept in a test 
tube filled with mercuric bichloride, 1 to 1,000. The test tube 
may be closed with a rubber cork, marked with a number or 
letters to designate the patient for whom the nozzle is used. 

The indications for irrigations, their technique, and the 
solutions employed will be considered under the special heads 
where they properly belong. 



II. ACUTE ANTERIOR GONORRHOEA. 

In intromission during sexual intercourse the lips of the 
meatus are more or less pressed apart, causing the meatus to 
gape. On each withdrawal the lips are pressed together by the 
same vaginal pressure that pressed them apart on insertion. 
This gives the meatus a motion which may be compared to the 
opening and closing of a fish's mouth when feeding. If the 
vagina harbors gonococci, and if the penis is part of a body 
with lowered resistance, the infection, however reduced in the 
female, will find a new culture ground in the male urethra. 

In contravention to this it may be offered that gonorrhoea 
most frequently affects men in the best possible physical condi- 
tion. It is equally true, though, that men in full vigor are the 
most likely to expose themselves to venereal infection. 

Again, a number of persons appear who contracted gonorrhoea 
without intromission, such as, for instance, when emission of 
semen took place before the penis could be inserted into the 
vagina. These are easily explained by the fact that the female 
urethra and Bartholini's glands are a very frequent site of re- 
sidual gonorrhoea. 

Extra-genital gonorrhoea, i.e., its acquisition otherwise than 



ACUTE ANTERIOR GONORRHCEA. 9 

from an infected female, as for instance from a water-closet, is 
improbable, unless a man with an immense meatus were to reck- 
lessly smear it over the seat upon which gonorrhceal discharge 
had been left by another. Taylor 1 says that the acquisition of 
gonorrhoea on a " foul privy or urinal may be looked upon as a 
euphemism to be used in the case of some clerical, venerable, 
or married transgressor." 

One distinct case of extra-genital gonorrhceal infection, how- 
ever, came under my observation in 1897. A gentleman had 
contracted gonorrhoea fifteen years before. The case was per- 
sistent and followed by stricture, for which his physician used 
sounds. These had been discontinued for several years. The 
patient had for five years been engaged in severe mental labor, 
during which, as happens under such circumstances, he experi- 
enced no sexual desire. A few months before being sent to me 
he became engaged to be married. He had forgotten everything 
connected with his former gonorrhoea and stricture. Two 
months before the day set for his wedding, this gentleman, 
while in the rooms of a friend, saw a sound lying on the wash- 
stand. It was a 30 F, the same number he had last used. To 
ascertain whether his urethra had preserved its calibre, he es- 
sayed introduction of the sound into his own urethra, and found 
no difficulty in doing so. Three days later he had all the evi- 
dences of acute gonorrhoea. If this patient's veracity were not 
beyond dispute, the etiology of his attack might have been 
questioned. An examination of his discharge showed distinct 
gonococci grouped within pus corpuscles, attached to epithelia 
and disseminated between them. The friend whose sound was 
borrowed had no discharge, but ramonage of his urethra proved 
that it contained gonococci. 

Some time later the Centralblatt fur Krankheiten der Ham- 
und Sexual- Organ e contained a report made by the patient (a 
physician) to show an extraordinarily long period of incubation 
of gonorrhoea — three weeks. The manner of infection is equally 
interesting. The doctor had taken a specimen of a fresh gon- 
orrhceal discharge for microscopic examination. Through care- 
lessness he had soiled his fingers with the discharge. Being 
suddenly seized with a desire to urinate, he quickly took his 

1 Taylor : The Pathology and Treatment of Venereal Diseases, 1895. 



10 THE IRRIGATION TREATMENT OF GONORRHOEA. 

penis from his garments, and in doing so communicated some 
of his patient's discharge to his own meatus. The result was a 
fully developed gonorrhoea. 

There doubtless may be similar cases of extra-genital infec- 
tion, still they are exceedingly rare. At all events, when as- 
serted, it can do no harm to give the patient the benefit of the 
doubt. 

When gonococci have entered the meatus, they at once pro- 
ceed to proliferate by segmentation. At any time between 
twenty -four hours and nine or ten days post coitum, the lips of 
the meatus are reddened, swollen, and a watery oozing presents. 
This soon becomes successively whitish, white, whitish-yellow, 
yellowish, yellow, yellowish-green, and later on possibly stained 
with blood. With deepening of the color the discharge becomes 
more copious and thick. 

The other symptoms of acute anterior gonorrhoea merit at- 
tention. White and Martin 1 hold that even preceding the first 
slight puffing of the meatus, the patient experiences a constant 
desire to handle and examine the penis. I believe that this is 
not likely to occur except in those patients who have had gonor- 
rhoea before, or in married men who have had illicit intercourse. 
This direction of the patient's mind to his penis may be due to 
that "conscience does make cowards of us all." 

Coincident with or shortly before the first slight tumefaction 
of the meatus, there may, however, be a tickling in the affected 
region. This is soon followed by a sense as if the urine were 
very hot. Replying to the irritation caused by the increased 
number of the gonococci seeking more food in the urethral 
mucosa, nature tries to wash away the disturbance by increased 
urination and increased secretion of urethral mucus. The pa- 
tient, yielding to the more frequent calls to urination, experi- 
ences intense scalding and cutting pain with each act. When 
the gonococci have caused the destruction of the mucosa in 
spots, the pain on urination" becomes intolerable, to subside 
only after the gonococci have exhausted their food supply of 
mucosa, or when the nerve terminals are protected by tissue 
hyperplasia. 



1 White and Martin : Genito-Urinary Surgery and Venereal Diseases, 
Lippincott, 1898. 



ACUTE ANTERIOR GONORRHOEA. 11 

Coincident with the irritation, the urethra and its adjacent 
tissues are the site of blood afflux. Its results will be con- 
sidered under the complications of acute gonorrhoea. 

As the pains on urination grow more severe, the first 50 to 
100 c.c. (fl 3 ii. to fl 1 iii.) become turbid. Caustic potash 
added to this urine shows it to be laden with pus. The pain 
may, however, be entirely absent or may, in severe cases, con- 
tinue even between the intervals of urination. 

This mere outline of a sketch of the development of a clap 
premises its arrest at or before the compressor, i.e., when it re- 
mains an uncomplicated anterior gonorrheal urethritis. That 
it rarely does so is only too evident to physicians who give the 
subject careful attention. 

Many text-books advocate "waiting for the acute stage to 
pass off." This waiting unfortunately allows the gonococci to 
increase, the infection to invade the tissues more deeply, to pro- 
ceed beyond the compressor, to develop local complications, to 
involve other organs, and to make a life-endangering disease of 
what should have been arrested in its incipiency. 

So far as our present knowledge goes, the end in view is best 
attained by irrigations, employed as early as possible. How 
the irrigations exercise a beneficial effect may be subject to hon- 
est differences of opinion. 

Potassic permanganate, the drug most frequently employed 
for the purpose, is held to liberate oxygen in the tissues ; if the 
gonococcus is an anaerobic microbe, it would die in the presence 
of oxygen. Then irrigations of hydrogen peroxide should have 
a more prompt effect, which, however, is disproven in practice. 

The theory that seems most acceptable is that the large 
volumes of hot water (110° to 120° F.) employed induce a species 
of artificial oedema of the urethra, making it an unfavorable cul- 
ture medium for gonococci. At all events, it is nothing rare to 
find the heavy greenish or bloody discharge, the frightful pains 
on urination, converted into a mere watery excess and painless, 
normal urination after one or two irrigations. Even if the 
course of the disease were not abbreviated and complications 
avoided by irrigation, these two results alone would justify 
ardent advocacy of this method of treatment. 



12 THE IRRIGATION TREATMENT OF GONORRHOEA. 



III. ANTERIOR IRRIGATIONS. 

Irrigations of the anterior urethra are employed : 

1. In infection of the anterior urethra; 

2. After any instrumentation of the anterior urethra, whether 
for diagnostic or therapeutic purposes. Since making it an in- 
variable rule to irrigate the uretha even after urethroscopy, I 
have had not a single case of urethral fever to record. 

The technique of anterior irrigations may be divided into 
preparation of the patient and the performance of the irrigation 
itself. Their necessarily detailed description may male them 
appear complicated and difficult ; their proper execution, how- 
ever, is simple and easy. The time they consume never ex- 
tends over five minutes, even with a very sensitive or apprehen- 
sive patient receiving his first irrigation. As soon as the patient 
has learned the painlessness of a gentle, properly executed irri- 
gation and has experienced the relief it affords him, he becomes 
the physician's active coadjutor in further treatment. 

Preparation of the Patient. — After the record of the case is 
written, a specimen of the discharge taken for microscopic ex- 
amination, and the urine examined, the patient is instructed : 

1. To drop his trousers to his knees. 

2. To fold his shirt and undershirt upward, exposing the 
abdomen. 

3. To sit on a chair with a firm, strong back, in such a posi- 
tion that his weight does not rest upon the tuberosities of the 
ischium but upon the sacrum ; in other words, he is placed as 
far forward as possible upon the front margin of the chair. 

4. To rest his shoulders against the back of the chair. 

5. To plant the soles of his feet firmly upon the floor. 

6. To direct his face upward, toward the ceiling. It is well 
always to give this last instruction, lest a patient with a malo- 
dorous breath discover that an invidious distinction is made in 
his case. This position serves the good purpose of saving the 
physician the unnecessary disagreeable knowledge that would 
otherwise interfere with his work. 

When the bad odor of the breath is due to digestive disturb- 
ance it should be remedied by appropriate treatment as quickly 



ANTERIOR IRRIGATIONS. 



13 



as possible, so that no other condition may reduce the patient's 
resistance to further invasion of the gonococci. 

7. If the physician is not experienced in irrigations, it is 
well to protect the patient's garments with a large rubber apron, 
made for the purpose with a hole for the penis. 

8. A pan or bowl of tin or agate ware is then washed, inside 
and out, in hot running water and then wiped dry. It is well to 




|p "]l ""<! l\ ] ") "" 1 J~l 



1 T - 1 "i ''] ) 



^/vr- 



Fig. 7.— Posture of Patient for Irrigation in Recumbent Position. 



do this before and after each irrigation, and in such a manner 
that the patient must observe the precaution ; it aids in keeping 
his attention fixed upon the need of taking every care against 
infection of others and of auto-reinfecfcion. 

9. A clean towel is placed upon the patient's lap and drawn 
up to cover his testicles, but not his penis. 

10. The basin, still warm from its cleansing in hot water, is 
placed upon the towel, and the patient is told to hold it with 
both hands. The penis is laid upon the margin of the basin 



14 THE IRRIGATION TREATMENT OF GONORRHOEA. 

and the latter slightly tilted, so that the rim upon which the 
penis lies encroaches upon the peno-scrotal juncture. 

Excessively nervous patients may be inclined to faint on 
merely receiving the above instructions. It is well to irrigate 
such patients in the recumbent posture. For this purpose place 
a bidet or irrigating pan upon the operating-table. Draw the 
patient's linen well up to beyond his lower ribs, and his trou- 
sers and drawers down to below his knees. Let his buttocks rest 
far back on the pan, to leave as much of it exposed as possible. 
Place a tin bowl between his knees, tilted with its concavity up- 
ward, so that any untoward motion on his part sending the irri- 
gating fluid beyond the shield may be caught by the bowl and 
directed into the pan upon which he lies. The irrigation may 
then be made as easily as when the patient is seated, and with- 
out danger of his fainting. 

In very exceptional cases, perhaps once in a thousand, a pa- 
tient is found who unconsciously responds to irrigations by a 
relaxation of the compressor. The consequence is that the fluid 
intended for anterior irrigation enters the bladder. When a 
very strong solution (such as potassic permanganate, 1 : 500) 
is used, a very severe vesical tenesmus at least is induced there- 
by. In such cases it is best to irrigate the patient in the stand- 
ing posture, and to teach him to press his fingers upon the 
perineal portion of the urethra to occlude it. 

Technique of an Anterior Irrigation. — 1. Stand at the pa- 
tient's right side. 

2. Cleanse the penis, foreskin, glans, and meatus with cotton 
tampons soaked in mercuric bichloride, 1:3,000. If it is pre- 
ferred to accomplish the cleansing with the irrigating solution ; 
then 

3. Take the stopcock in the right hand as shown in Fig. 4, 
page 5, and for additional safety pass it under running boiling 
water, into which a small quantity of the irrigating fluid should 
be allowed to escape ; then close the flange. 

4. Take the penis in the left hand, holding the left corpus 
cavernosum by the third, fourth, and fifth fingers in such a 
manner that their tips rest lightly upon the urethra. The left 
thenar eminence, by being pressed inward, compresses and al- 
most grasps the right corpus cavernosum. The bent thumb and 
index finger are thus left free for manipulation of the foreskin, 



ANTERIOR IRRIGATIONS. 



15 




glans, and meatus. Tins manner of holding the penis will at a 
first effort appear to cramp the hand, but after two or three irri- 
gations it will be found the most effective and easiest. 

5. Gently draw the flange of the stopcock back by contract- 
ing the right thumb and index finger. This will allow a fine 
stream to escape from the nozzle. Direct this stream to the 
outer surface of the foreskin until all its parts are thoroughly 
cleansed. 

6. Increase the stream slightly while directing it to the 
opening of the foreskin. With the left thumb and index finger 
slowly evert the foreskin 
and, as its mucous lin- 
ing is thus being ex- 
posed, wash each part 
as it comes into view. 

7. When the entire 
foreskin is retracted, 
wash the sulcus behind 
the corona, the glans, 
the sulci at either side 
of the frenum, and the 

lips of the meatus in the same manner. When the foreskin is so 
tight that it cannot be everted, drop the penis and take up the 
top of the foreskin with the left thumb and index fingers. This 
will leave the opening of the foreskin slightly gaping. Insert 
the nozzle into the opening of the foreskin and increase the force 
of the stream until the preputial pouch is thoroughly ballooned. 
Give the tip of the nozzle every possible direction, so that the 
pouch may thus be as effectively cleansed as possible. 

8. After cleansing the foreskin, glans, etc., and holding the 
penis as shown in Fig. 8, above, contract the thumb and index 
finger upon the glans, so as to open the meatus. 

9. Direct the stream at first gently and then with increasing 
force into the opened meatus, until all visible excess of secretion 
is washed from it. 

10. Bring the nozzle closer and closer to the meatus until its 
point is within the lips. 

11. Compress the urethra with the tips of the left third, 
fourth, and fifth fingers, to entirely occlude it. 

12. Augment the force of the flow until the fluid spurts from 



Q.-r\s> 



FIG. 8.— Manner of Holding Penis for Irrigation. 



16 THE IRRIGATION TREATMENT OF GONORRHOEA. 

the meatus in such a manner that it is received by the shield 
and flows from it into the basin held by the patient. The im- 
pact of the fluid is felt against the tip of the middle finger, where 
it compresses the urethra. 

13. When one-fifth of the contents of the percolator are con- 
sumed in the irrigation of the anterior third of the anterior 
urethra, the middle finger is relaxed and the fluid's impact is 
immediately felt upon the tip of the fourth left finger that com- 
presses the urethra. 

14. The same procedure is successively observed regarding 
the urethra compressed by the fifth left finger, and the impact 
of the fluid, with increased force, is sent to the bottom of the 
anterior urethra, i.e., to the anterior surface of the mucosa in 
front of the compressor. 

During every step of an anterior irrigation enough force 
must be used to fully dilate (balloon) the urethra. The nozzle 
should never occlude the meatus entirely, especially when strong 
solutions are used, lest they be forced beyond the compressor 
into the bladder. 

The division of the amounts of fluid used for each part of the 
urethra will soon become so much a matter of routine that the 
operator need not observe the percolator to guide him. 

After each irrigation a layer of absorbent cotton soaked in 
mercuric bichloride, 1:6,000, should be placed upon the glans 
to receive any subsequent discharge, preventing as far as pos- 
sible auto-reinfection, and to keep the clothing clean. If the 
foreskin is absent or too small to hold the cotton, it should be 
fixed in place by means of a light gauze bandage. The patient 
should be instructed to apply a clean piece of cotton soaked in 
bichloride after each urination. 

Some cases are exceedingly susceptible to the irritant effect 
of mercuric bichloride, even a solution of 1:10,000 or of 1 : 
30,000 sets up an inflammation of the glans. Boric acid, four 
per cent., may be used in such cases to wet the cotton. 

The cotton used as above must not be substituted by any- 
thing else. Gonorrhoea-bags and condoms, so often advised for 
the purpose, keep the glans macerated in pus, not only inviting 
persistent auto-reinfection, but also exposing the glans to gon- 
orrhceal balanitis, for whose existence there is no excuse. 

Some authors recommend a little apron made of linen or 



ANTERIOR IRRIGATIONS. 17 

gauze, cut about two inches square, with a slit in the centre to 
let the glans pass through. The ends of the apron are then 
folded forward to cover the glans and meatus. If the patient be 
sure to take off this apron each time he urinates and replace it 
with a fresh one, its convenience might make it advisable to a 
degree. But it is entirely too convenient merely to open the 
ends, urinate and replace the soiled ends over the glans. More- 
over, the ends are easily brushed open and thus the garments 




Fig. 9.— Anterior Irrigation, Patient Seated. Towel over thighs omitted for clearness of illus- 
tration. 

are exposed to being soiled by the pus. For these reasons it is 
best to use absorbent cotton, as above suggested. 

All parts of an irrigation can, without any special dexterity, 
be so conducted that neither the patient's garments, his person, 
nor the office floor be soiled. Nothing need be stained, except 
the operator's left fingers, when using strong solutions of potas- 
sic permanganate. They can be quickly cleaned with oxalic acid 
or sodic bisulphide. 

As cleanly as an irrigation should be, so painless it is when 
properly carried out. Even an intensely inflamed urethra ex- 
periences no pain if the operator is sufficiently gentle. In 
this, as in all other genito-urinary work, suaviter in modo occu- 
pies first place ; fortiter in re need not at all suffer thereby. 
2 



18 THE IRRIGATION TREATMENT OF GONORRHOEA. 

For this reason analgesia of the urethra with cocaine or eucaine 
need not be induced. Moreover, when their obtunding effect 
wears off, the patients experience more pain than if they had 
not been used at all. 

The time consumed by irrigations has been alleged as an ob- 
jection to their employment. A deliberate, properly conducted 
anterior irrigation requires about two minutes, certainly not too 
much time to devote in each visit to so important a disease as 
anterior gonorrhoea. If only relief from suffering were obtained 
thereby, even ten times two minutes would be well employed. 
But the physician, knowing how dangerous to life gonorrhoea is, 
should not begrudge any amount of time and labor directed to 
this end. Even if the disease was acquired in the grossest im- 
morality, even if the patient is of the lowest, most degraded type, 
it is unqualifiedly the physician's duty to give the best efforts 
in order to prevent the dissemination of the disease to others 
who may possibly be innocent of any wrong. 

The frequency with which irrigations should be employed 
in acute anterior gonorrhea is set forth in the following table. 
The solutions referred to therein are of potassium permanganate, 
— the drug most frequently used by all who employ irrigations. 
Trie dilutions are modified from those advised in Janet's tables, 
which, for some reason, seem too strong for use in this country. 
It will be observed that intravesical irrigations appear in this 
table. The technique of these will be described in Chapter V. 
(Intravesical Irrigations) : 

First day, first visit. Anterior irrigation 1 : 3,000 

First day, 7 p.m. Anterior irrigation 1 : 4,000 

Second day. 9 a.m. Anterior irrigation 1 : 3,000 

Second day, 7 p.m. Anterior irrigation 1 : 4,000 

Third day, 9 a.m. Intravesical irrigation 1 : 6,000 

Third day, 7 p.m. Anterior irrigation 1 : 5,000 

Fourth day, 9 a.m. Intravesical irrigation 1 : 5.000 

„ ', -, - ( Intravesical irrigation 1 : 5,000 

Fourth day, 7 p.m. ° „ ' „. 

( Anterior irrigation 1 : 2,000 

Fifth day, noon. Intravesical irrigation 1 : 5,000 

Sixth day, noon. Intravesical irrigation 1 : 5.000 

Seventh day, noon. Intravesical irrigation 1 : 5,000 

-,. ... , n ( Intravesical irrigation 1:5,000 

Eighth day, 9 a.m. \ & 

( Anterior irrigation 1 : o.OOO 

Eighth day, 7 p.m. \ Intravesical irrigation 1 : 5,000 

5 J ( Anterior irrigation 1 : 2.000 



ACUTE POSTERIOR GONORRHOEA. 19 

Ninth day, 9 a.m. \ Intravesical irrigation 1 : 4,000 

( Anterior irrigation 1 : 1 ? 000 

Ninth day, 7 p.m. i Intravesical irrigation 1 : 4.000 

( Anterior irrigation 1 : 1.000 

Tenth day, 9 a. m. i Intravesical irrigation 1 : 4,000 

( Anterior irrigation 1:1 ,000 

Tenth day, 7 p.m. J| Intravesical irrigation 1 : 5,000 

I Anterior irrigation 1 : 500 

The hours at which irrigations are to be administered have 
been fitted to the exigencies of most physicians' office hours. 
It would be always preferable, however, when irrigations are to 
be given twice in one day, that they be made twelve hours apart. 



IV. ACUTE POSTERIOR GONORRHOEA. 

De Keersmaecker and Yerhoogen 1 in brief remarks on acute 
posterior gonorrhoea, say : " The inflammation proceeds along 
the whole urethral mucosa, but its intensity decreases generally 
in accord with its distance from the point where the inoculation 
was produced, as is observed in every local infection. " It seems, 
however, that posterior gonorrhceal invasion is an exception 
hereto. The gonococci having traversed the compressor find a 
new field of culture in the posterior urethra. They often set up 
an inflammation far exceeding in virulence that which affects 
the anterior urethra. In mam* cases the patient's sufferings 
are not only materially increased, but, as Posner says, "the 
portals for infection of other organs are thereby thrown open." 

Jadassohn holds that sixty to seventy per cent, of anterior 
gonorrhoeas invade the posterior urethra ; Finger places the ex- 
treme figure at eighty per cent. ; while Taylor 3 claims that "an- 
terior urethritis in between eighty and ninety per cent, of cases 
within the early days of infection passes backward and involves 
the posterior urethra." Close clinical study of the question 
makes it appear likely that even Taylor underestimates the fre- 
quency with which the posterior urethra is involved in the dis- 

5 De Keersmaecker et Verhoogen : L'Ur<§thrite chroniqne, Brussels, 1898. 
-Posner: Diagnostic der Harnkrankhei ten. Berlin, 18i>4. 
3 Taylor : The Pathology and Treatment of Venereal Diseases, Lea Bros. & 
Co., 1895. 



20 THE IRRIGATION TREATMENT OF GONORRHOEA. 

ease. Indeed White and Martin 1 say that the gonococcus " with 
but few exceptions invades the posterior urethra. " 

Wossidlo 2 urges that no apparently cured case of acute gon- 
orrhoea be dismissed without examination of the prostate, al- 
though the posterior urethra does not seem to have been affected. 
The absence of symptoms of posterior urethritis is no proof that 
the posterior urethra was not infected by the gonococci on their 
way to the adnexa. 

Causes. — Anything that decreases the vital resistance of the 
posterior urethra, menaced by the presence of anterior gonor- 
rhoea, and increases the intensity of the latter, is likely to pro- 
duce posterior gonorrhoea. Among the most frequent causes are 
neglect of treatment, coitus, irritants applied to the urethra, alco- 
hol, fermented or carbonated beverages, and excessive activity. 

Time of Invasion. — A neglected or badly treated anterior 
gonorrhoea usually invades the posterior urethra by the end of 
the first week. The patient, however, may perceive no symp- 
toms thereof until the end of the second week. A few days later 
the evidences are often too marked to escape attention. 

Posterior gonorrhoea may, on the other hand, become pain- 
fully manifest at the very beginning of the disease, especially 
if strong injections, violently applied, increase the irritation. 
This may convey to those not familiar with the irrigation treat- 
ment, a condemnation of its employment. But it must be re- 
membered that the irrigations applied to the entire urethra are 
not strong ; moreover, they so modify the urethral mucosa as to 
make it an unfavorable culture medium for gonococci. This in 
a measure explains the absence of posterior gonorrhoea when 
irrigations are properly employed. 

Some authors mention the use of bougies as a means of im- 
mediately establishing a posterior gonorrhoea. Naturally they 
do this only to condemn the insertion of any instrument into an 
acutely inflamed urethra. Ipse facto, this is a condemnation of 
attempting to wash the urethra with a catheter or treat it with 
anthrophores. 

Symptoms. — As noted above, very many cases of acute pos- 

1 White and Martin : Genito-Urinary Surgery and Syphilis, Lippincott, 
1898. 

2 Wossidlo: "Chronic Prostatitis and Its Treatment." Journal of the 
American Medical Association, August 27th, 1898. 



ACUTE POSTERIOR GOXORRHCEA. 21 

terior gonorrhoea are insiduous in their onset, course, and decline. 
Most of these disappear without any special treatment being 
directed to the region infected. Indeed in former times the 
posterior urethra was deemed one of the " sacred regions " not 
to be entered by instruments or drugs, and yet many cases ap- 
peared to have recovered. How many of these subsided after 
carrying gonococci to the urethral adnexa and general organism 
is beyond calculation. The hope of those who strive to heal 
acute posterior urethritis by treatment of the anterior urethra 
alone, may be compared with that of the gynecologist who en- 
deavors to drain pus-tubes by curetting, washing, and draining 
the womb. Both appear to succeed often; but as concerns pos- 
terior urethritis, the physician would fall short of his duty if he 
risked further complications by trusting to the chance that oc- 
casionally seems to have favored the past. 

Mechanism of the Symptomatology. — In the insidious form, 
the very slight sufferings or their absence may not direct atten- 
tion to the posterior urethra. In the severe form, nature endeav- 
ors to assuage the inflammation by free secretion of urine. Its 
contact with a surface rendered exquisitely sensitive produces 
intense burning. After the flow of urine has ceased, the in- 
flamed surfaces fall against each other, and in so doing give the 
sensation of an incompletely accomplished urination. At the 
same time the folds of the thickened mucosa squeeze between 
them the delicate nerve terminals, producing the characteristic 
after-pains. When somewhat deep denudations have taken place, 
the capillaries may break, allowing blood to escape, which may 
be mixed with the last portion of the urine, may follow it as 
clear drops ; or a distinct stream of blood may flow, or the urine 
may carry small worm-like clots, if blood coagulates in the pos- 
terior urethra. 

The swelling of the mucosa and pain evoke frequent, almost 
continual spasmodic and semi-voluntary contractions as if in 
effort to eject the obstructions. This activity of the region in- 
creases the symptoms as it augments the inflammation. The 
vicious circle obtains another segment by each effort of nature 
to pour out urine. The latter becomes so frequent that the 
patient continually strives to empty his bladder, and while he 
fails to obtain a sense of relief, by acting upon the desire to uri- 
nate, he increases his pain. 



22 THE IRRIGATION TREATMENT OF GONORRHOEA. 

As above suggested, there is no exact chronological order in 
which the manifestations of acute posterior urethritis follow each 
other. Indeed, they may all appear to come on together with 
extreme severity. For convenience in studying them a little 
more closely, they are here placed in alphabetical order. 

Albuminuria. — When the urine carries pus, it accounts for 
the presence of a proportionate amount of albumin. In acute 
posterior gonorrhoea, when vesical tenesmus is at its highest, 
the amount of albumin carried by the urine exceeds that which 
would be expected from the amount of pus present. White and 
Martin 1 deem this excess " probably due to damming back of 
the urine in the ureters, dependent upon closure of the orifices 
of these canals by contraction of the detrusor muscles of the 
bladder ; this having been shown to take place when tenesmus 
is severe." 

Complications. — Proximity and continuity of mucous surface 
render the prostate, seminal vesicles, and epididymides exceed- 
ingly susceptible to infection from posterior gonorrhoea. The 
epithelium covering the trigone, from its similarity in character 
to that of the posterior urethra, is also liable to the infection, 
but to a limited degree. The epithelium lining the body of the 
bladder, however, seems immune to gonorrhceal infection, ex- 
cept when a pre-existent disease has weakened its resistance, 
or when traumatism has been exerted upon it, as by the abuse 
of instruments. 

Constitutional Symptoms. — When a patient with gonorrhoea 
suffers from loss of appetite, headache, constipation, marked 
mental depression, even to profound neurasthenia, and appre- 
ciable fever, the physician's attention is naturally directed to 
the probable invasion of the posterior urethra. These general 
symptoms may come on gradually or suddenly, and are as likely 
to occur in chronic as in acute anterior gonorrhoea. If given 
immediate attention, severe general suffering and more danger- 
ous involvement of the urethral adnexa may be averted. 

Discharge. — The tonic contraction of the compressor prevents 
the discharge of acute posterior gonorrhoea from entering the 
anterior urethra. When it is so copious as to fill the posterior 
urethra, the slight, weak bundle of fibres constituting the 

1 Op. cit. 



ACUTE POSTERIOR GONORRHOEA. 23 

sphincter vesicae is more likely to yield to the pressure and so 
admit the discharge into the bladder. Even stripping the 
posterior urethra per rectum will not aid satisfactorily in the 
production of discharge from the posterior urethra, for the same 
reasons as given above. The only means of positively reaching 
conclusions regarding involvement of the posterior urethra, in 
addition to giving due heed to the other symptoms, is by ex- 
amination of the urine (vide Urine infra). Naturally when the 
symptoms appear in the fulminant type, this aid to diagnosis 
is impossible and would be superfluous. 

Emissions. — JVs abstinence from sexual intercourse is impera- 
tive during gonorrhoea, for the patient's sake as well as for the 
sake of those to whom the disease may be communicated by 
him, and as the local irritation of even an anterior gonorrhoea is 
prone to stimulate increased secretion of semen, seminal emis- 
sions are not infrequent. They occur especially in men who are 
given to daily sexual intercourse. When, however, posterior 
urethritis has produced hyperesthesia of the caput gallinaginis, 
the emissions of semen may be exceedingly painful, the suffer- 
ings being either disseminated through the perineum, extend- 
ing up to the rectum, or tearing and shooting along the posterior 
urethra. These pains are often so intense that the patient is 
afraid to fall asleep, lest he be awakened by an emission that 
would evoke their recurrence. 

Erections. — Posterior urethritis is liable to provoke erections 
at all times, with or without erotic incitation. They are most 
frequent when warm in bed, but are painless unless there be 
acute anterior urethritis as well. 

Hematuria. — Drops of blood, unmixed with urine, may 
escape from the urethra at the end of micturition. This is usu- 
ally considered a positive evidence of posterior urethritis. 
While it most frequently occurs in this disease, it may also be 
present in some forms of bladder growths (polypus, papilloma) 
and stone. When due to posterior urethritis, the bleeding comes 
from the swollen, congested, and even eroded mucosa. If the 
bleeding is copious it may flow into the bladder and be mixed 
with its contents ; then, too, some drops or a jet of clear blood 
will follow urination. In such a case the urine may also carry 
small, worm-like clots of blood. 

Pain. — The pain of fulminant acute posterior urethritis is 



24 THE IRRIGATION TREATMENT OP GONORRHOEA. 

usually most marked in the perineum. It is due to muscular 
spasm, provoked by the tenesmus. Its severity may be so great 
as to cause the patient to act as if afflicted with acute mania. 
Between the attacks of intense pain the patient may have tick- 
ling, burning, and sharp lancinations through the deep urethra, 
extending up the rectum. All these disturbances are aggravated 
by urination or defecation ; they most frequently follow the act 
of urination. 

Retention of Urine. — If the posterior urethra is very much 
swollen, the frequency of urination may suddenly be arrested 
and acute retention take its place. The sufferings that before 
were somewhat remittent then become continuous. The reten- 
tion may become quite obstinate from the increase of swelling 
and reflex tonic contraction of the sphincters. (See also Com- 
plications of Gonorrhoea : Retention. ) 

Urination. — The slightest quantity of urine coming into con- 
tact with the inflamed posterior urethra provokes the desire to 
urinate. The patient must then micturate every few minutes. 
His straining to pass the few drops is accompanied by intense 
pain. Although passage of these drops gives no relief, the 
patient continues his efforts to urinate incessantly, being im- 
pelled thereto by the sense of vesical repletion. His only relief, 
when not treated, is in the few moments of sleep or fainting that 
exhaustion brings. 

In a case that is not so acute as the one described, there 
may be no painful straining. But the urination is frequent and 
imperious. The desire when felt must be immediately gratified, 
otherwise the patient will urinate into his trousers. 

Urine. — When acute disturbances of urination do not pre- 
vent examination of the urine, and when the other symptoms or 
conditions direct attention to the posterior urethra, the only 
method of reaching a diagnosis is by examination of the urine. 
Even when no suspicion guides to thoughts of posterior urethral 
invasion, the urine of a gonorrhoeic should be examined daily, 
so that the extension of the disease may be met at its inception. 

The examination should be made, if possible, of the first 
urine the patient passes in the morning. When this is not pos- 
sible, because of the distance at which the patient lives from the 
physician's office, the examination may be made during the day, 
but after the patient has held his urine for at least four hours. 



ACUTE POSTERIOR GONORRHOEA. 25 

The patient should be caused to pass the first portion, about 
150 c.c. (fl 3 v.) into a twelve-inch ignition tube. 1 This washes 
the anterior urethra as clean as possible, but naturally carries 
with it as much discharge from the posterior urethra as can be 
easily detached from its walls. The urine so emitted will there- 
fore often be much more turbid than would be expected from a 
slight discharge. 

The second 150 c.c. emitted into another tube, if the patient 
have posterior urethritis, will be found more turbid than the 
first portion. Naturally this symptom is not characteristic if 
the patient have cystitis or pyelitis, or when a disease of the 
prostate or seminal vesicles causes their contents to be expressed 
with the final efforts of micturition. In the absence of these 
diseases, and when the posterior urethra produces much dis- 
charge, it may flow back into the bladder and render its con- 
tents turbid. If the discharge is not copious, it will be carried 
off by the first urine, and leave the subsequent urine clear. 
Both urines, however, may be clear when the patient urinates 
frequently. 

. To cover the possibility of error in these cases, practitioners 
are ordinarily advised to wash out the anterior urethra by means 
of a soft catheter before allowing the patient to urinate. The 
greater ease and safety by which the urethra can be cleansed by 
means of anterior irrigations make the latter method preferable. 
By carefully exercising the technique of anterior irrigations (see 
page 12), and using warm boric-acid solution for the purpose, 
the anterior urethra can be quickly freed from any discharge it 
may at the time harbor. When the solution that spurts from 
the meatus is entirely clear of even fine granules, the patient 
should immediately urinate into two tubes. If the first tube 
contains pus and the second does not, the diagnosis of posterior 
urethritis is established with a fair degree of accuracy. 

A better and not much more circumstantial test, especially 
applicable when the urine is not turbid, can be made by add- 
ing to the boric acid used for irrigation a quantity of methylene 
blue representing one per cent, of its quantity (twenty-four grains 



1 These twelve-inch ignition tubes are erroneously called " Valentine's urine 
tubes " by dealers. I did nothing but suggest the convenience of these tubes 
for macroscopic examination, comparison, and chemical and microscopical 
investigations of urine. 



26 THE IRRIGATION TREATMENT OF GONORRHOEA. 

to the quart) . If the urine passed into the first tube contains 
shreds, filaments, flakes, or granules which the microscope shows 
to be stained blue, it would tend to prove that they come from 
the anterior urethra. If they are not stained by the irrigation, 
their source is the posterior urethra. 

The need of careful study and early treatment of posterior 
urethritis is evident, despite the fact that many of the cases 
appear to recover without treatment. Their tendency is to go 
over into a subacute or chronic state, to produce recurrent gon- 
orrhoea, and to evoke a long list of neuroses which are often in- 
effectually treated until the source of the evil is ascertained. 

Treatment. — As is quite natural, the treatment of acute pos- 
terior urethritis must vary in accord with the form in which it 
appears. If its onset is in the most insidious manner, so that 
its presence is determined only by examination of the urine, the 
safest, quickest, and easiest method of cutting it short is by 
intravesical irrigations, whose technique is fully detailed on 
page 29. 

These intravesical irrigations may be performed once daily, 
beginning with potassium permanganate solution of 1 : 6,000; on 
the second day the strength of the solution may be increased 
to 1:5,000; on the third day 1:4,000 may be used and if no 
reaction result, a further increase to 1:3,000 may be employed 
on the fourth and subsequent days. Some patients' bladders 
will very comfortably bear much stronger solutions. 

If in ii\e or six days the urine does not indicate complete 
subsidence of the posterior urethritis, mercuric bichloride may 
be added to the potassic permanganate solution last employed. 
The addition of the bichloride should at first not be stronger 
than 1 : 50,000. On the second day this may be made 1 : 40,000 ; 
on the third day 1 : 30,000 ; on the fourth day 1 : 25,000. Only 
in very persistent cases can 1 : 20,000 be employed. 

Some cases do better with the bichloride alone and in the 
solutions above indicated. 

Occasionally a case will be found in which neither the per- 
manganate nor the bichloride nor both in combination yield 
prompt effects. Then silver nitrate may be employed in solu- 
tions of 1 : 5,000, 1 : 4,000, 1 : 3,000, or 1 : 2,500, using the mildest 
on the first day and daily increasing the strength, but not beyond 
1:2,500. 



ACUTE POSTERIOR GONORRHOEA. 27 

These irrigations, when properly conducted, are borne ex- 
ceedingly well by patients ; they experience an almost immediate 
relief from the slight subjective or reflex symptoms due to the 
iDsidious form of the disease under discussion. 

When acute posterior gonorrhoea asserts itself in the fulmi- 
nant form, the prime indication is to break the before-described 
vicious circle at some point. As in all acute inflammations, 
rest of the affected region must be sought. 

Patients so affected should be kept in bed and on a diet of 
little else than skimmed milk. Mild laxatives, that keep the 
rectum clear and deplete the pelvic viscera, must be persistently 
given. 

The one drug that gives signal relief in hyperacute cases is 
santal oil. As was shown by investigations made in Berlin in 
1894 and 1895, santal oil cannot be expected to act as a gono- 
coccicide. 1 It does, however, prove a decided analgesic of the 
urinary apparatus, and especially its lower part. To procure 
its effect as quickly as possible, it may be given in ten minim 
doses every two hours for six or eight hours. As soon as the 
tenesmus begins to subside and the bleeding after urination 
materially decreases, the intervals should be increased to four, 
five, or six hours, until pain has entirely disappeared. As this 
drug is prone to evoke renal irritation, it should be withdrawn 
as soon as the indications for its use have subsided. 

The teas (infusions) of uva ursi leaves, herniaria, chenopo- 
dium, triticum repens, etc., which were formerly highly lauded 
for their presumed effects in such cases, have proven ineffective 
in my hands. They only augment diuresis, and in doing so in- 
crease the activity of the inflamed parts, that should be kept at 
rest. Salicylate of sodium and salol, which often show such fa- 
vorable results in cystitis, prove utterly inactive in acute poste- 
rior urethritis. 

When the attack is so severe that the effect of santal oil can- 
not be awaited, then morphine gr. \-\, especially in supposi- 
tories, will afford quick relief. When this does not act promptly 
iodoform, gr. -£, may be added to the suppository. Belladonna 
has yielded no results to me in doses that are safely adminis- 
tered. At the same time that the suppositories and santal oil 

] Valentine : "Der Einfluss der Balsamicis, insbesondere des Santalols auf 
Gonococcen." Pick's Archiv, April, 1895. 



28 



THE IRRIGATION TREATMENT OF GONORRHOEA. 



are used, local depletion may be hastened by the 
application of four to six leeches to the peri- 
neum. 

It is generally held that when acute gonor- 
rhoea suddenly invades the posterior urethra, 
direct treatment of the anterior urethra is contra- 
indicated. Comparison of the results of this 
neglect of treatment with those obtained by con- 
tinuing local treatment show to the decided ad- 
vantage of the latter. Therefore irrigations must 
be continued. If the patient is too weak to have 
them administered in the sitting posture, he may 
receive them while lying in bed. To facilitate 
such irrigations a sewing-board or leaf of an ex- 
tension table may be pushed under that part of 
the mattress beneath the patient's buttocks. With 
ordinary care, irrigations can then be performed 
without even moistening the bed-clothes. 

It is more particularly in the exceedingly severe 
cases which persist despite all the treatment above 
described that intravesical irrigations of potassium 
permanganate give prompt relief. The hot (110° 
to 120° F.) antiseptic solutions, very gently ad- 
ministered, seem to act as a soothing poultice to 
the inflamed, eroded posterior urethra. It is not 
rare to see a patient after such an irrigation fall 
asleep and rest comfortably for several hours, to 
awake much relieved. 

Guyon uses several drops of a one to two per 
cent, silver nitrate solution instilled into the pos- 
terior urethra. While the relief so obtained can- 
not be denied, the local reaction that follows is 
frequently very severe. This may be limited by 
precedent appreciable doses of morphine, by pre- 
liminary instillation of a few drops of cocaine if 
one is sure that the patient is not too susceptible 
to its toxic effects, or by giving the patient a quarter of a tea- 
spoonful of sodic bicarbonate (Kobner) thirty minutes before 
making the instillation. 

If, for anj r reason, irrigations cannot be employed, Guyon's 



POSTERIOR OR INTRAVESICAL IRRIGATIONS. 29 

instillations may be used every two or three days. The severe 
pains they produce can be very materially reduced, and often 
entirely avoided, if Guy on' s technique be closely followed. 

The instrument found best for the purpose is Albarran's 
modification of Guy on' s instillator. It consists of a syringe, a 
little larger than the ordinary hypodermic syringe, with a rod 
passing through the piston, by means of which the packing can 
be rendered tight or loose at will. A tightly fitting metal funnel 
serves to connect the syringe with a rubber capillary catheter 
shaped like a bougie a boule, and soft enough to be easily in- 
serted. Each complete turn of -the handle deposits a drop of 
the solution in the posterior urethra. If the deposits are made 
by quarter turns, and consequently by quarter drops, with an 
interval of ten to twenty seconds between each application, the 
pain will be minimized, larger quantities can be introduced, and 
a quicker effect obtained (Guy on). 



V. TECHNIQUE OF POSTERIOR OR INTRA- 
VESICAL IRRIGATIONS. 

Keeping in mind how feeble a bundle of muscular fibres 
constitute the sphincter vesicae, it is evident that any appreciable 
quantity of fluid carried into the posterior urethra through the 
strong compressor must enter the bladder. Hence irrigation 
of the posterior urethra distinctly implies irrigation of the 
bladder at the same time. For convenience, therefore, irriga- 
tions of the posterior urethra are called intravesical irriga- 
tions. 

Preparation of the Patient. — The patient is prepared and sits, 
stands, or lies down, as may be necessary, under the rules de- 
tailed on page 12. 

Tlie Irrigation. — 1. Perform thoroughly all the steps de- 
scribed under Anterior Irrigation (page 16), using only half the 
quantities of fluid there mentioned. 

2. Hold the penis firmly, while gently sinking the nozzle 
into the meatus, until it is entirely occluded thereby. At the 
same time slowly increase the force of the flow, by drawing back 
the flange of the stopcock. 

3. As the urethra is felt distending under the left finger tips. 



30 



THE IRRIGATION TREATMENT OF GONORRHOEA. 



order the patient to breathe deeply and slowly, and to make 
efforts at urination. 

4. Ordinarily when the third step of this operation is being 
performed, a sensation of purling of the liquid, as it enters the 
bladder, will be communicated to the left fingers. 

5. After one-half or three-quarters of a minute the inflow will 
become less accentuated and slower, as the bladder is being filled. 




Fig. 11.— Holding Basin and Stopcock and Handing Urinal to Patient. 



Then slowly push forward the flange of the stopcock, to dimin- 
ish the force of the flow, until it is stopped. By close observ- 
ance of this technique, the bladder can be entirely filled without 
producing pain or even an urgent desire to urinate. 

6. Best the penis on the margin of the basin, leaving the left 
hand free. 

7. Place the stopcock in the basin; pass the right thumb 
through its large ring ; pass the right fingers to the outside of 
the basin to hold it firmly with the stopcock. 

8. Extend the left hand to the shelf on which the glass 
urimils are kept (one may also conveniently stand under the 
patient's chair), take one and hand it to the patient. 

9. Order the patient to take his penis with his left hand and 
to direct it toward the urinal, which he holds in his right. 

10. Take the basin and stopcock from the patient's lap. 



POSTERIOR OR INTRAVESICAL IRRIGATIONS. 31 

11. Order tlie patient to void his bladder into the urinal; 
some can do this sitting, others must rise for the purpose. 

12. While the patient is emptying his bladder, pour the 
contents of the basin into the sink and wash out the basin with 
warm water, if the patient is to be immediately irrigated again. 
If not, wash the basin with boiling water, and place it with the 
used basins, to be thoroughly cleansed after office hours. 

13. Without removing the used nozzle from the stopcock, 
hold both under running, boiling water for a few moments. 
Then remove the nozzle and place it in a dish kept for used 
nozzles and containing mercuric bichloride 1:1,000. After 
office hours boil the used nozzles in water and caustic soda; 
rinse them in clean water and place them in a dish containing 
mercuric bichloride 1 : 1,000. 

All the steps of intravesical irrigation, like those of anterior 
irrigation, can be effectively, thoroughly, and painlessly per- 
formed without soiling any part of the patient's person or body, 
or of the office. 

Amount Required for Filling the Bladder. — The average male 
bladder can comfortably hold about 350 c.c. (nearly fl 3 xiss.); 
variations between 250 and 500 c.c. are, however, within the 
limits of health. 

Repetition of an Intravesical Irrigation. — Ordinarily after one 
irrigation the glass urinal shows its contents to be as clear as 
when the fluid was sent into the bladder. When this is not the 
case, the irrigation may at once be repeated. 

Impediments to Irrigation. — In some cases, when for any 
reason the preparations for irrigation are somewhat prolonged, 
or when the patient is nervous, there may be a somewhat free 
outpouring of urine from the kidneys, after the patient has 
emptied his bladder. A small quantity of urine in this viscus 
may set up such a spasm of the compressor that when an intra- 
vesical irrigation is attempted it cannot be overcome by the 
pressure of the irrigating fluid. Such a patient should be 
ordered to again empty his bladder ; the irrigation will then be 
quite easily performed. 

When potassic permanganate is used in a case in which some 
urine is withheld, it will be returned from the bladder either 
turbid or of a light straw or brownish hue. A second irrigation 
will then produce as clear a fluid as was used. 



THE IRRIGATION TREATMENT OF GONORRHOEA. 




Fig. 12.— Office Arrangement. A, Author's urethral and intravesical irrigator; upper margin 
of board attached to wall nine feet from floor ; B, stand eighteen inches high ; C, marble 
wash-stand (constructed by Mr. John H. Graham of New York); D, hot-water pedal ; E, cold- 
water pedal ; F, outflow trap ; G, mortar for rapidly making potassic permanganate solu- 
tions from tablets : H, glass urinal ; i, bottle containing potassic permanganate tablets, 2 
grains each; J. glass graduate 1,500 c.c. to measure urine; V, tray holding clean urine 



POSTERIOR OR INTRAVESICAL IRRIGATIONS. 33 

Some patients, in making violent respiratory efforts, coupled 
with endeavors to urinate during irrigation, will force the com • 
pressor into a firm tonic spasm. It is well, in such cases, to 
ask the patient to desist from his efforts, and, while reducing the 
hydrostatic pressure, to divert his attention from the matter in 
hand. This is best accomplished by some witticism ; not, how- 
ever, one of which the patient is the object. The slightest ten- 
dency of the patient to laugh is instantly accompanied by a 
relaxation of the compressor and a consequent inflow of the 
irrigation fluid into the bladder. 

Office Arrangement. — In a large genito-urinary practice much 
time can be gained and convenience secured by an office arrange- 
ment as shown in Fig. 12, page 32. It will be observed that the 
patient's chair stands on a platform. This is eighteen inches 
high, which is equivalent to irrigating the patient when the 
chair is on the floor and the irrigator raised only seven and 
one-half instead of nine feet from the floor. This reduction of 
pressure will make no difference to the physician experienced 
in irrigations. Moreover, the platform will prove very con- 
venient, when many irrigations must be done during the day, 
as it saves the physician much stooping. 

Physicians who are obliged to irrigate only a few patients 
daily do not need the somewhat expensive office arrangements 
here shown. They can do fully as effective and satisfactory 
work without. 

Further points concerning irrigations will be discussed 
under the conditions to which they especially apply. 



tubes ; K, small glass graduate to make solutions of silver nitrate, cupric sulphate, etc. ; K 1 , 
glass dishes holding sterilized nozzles in bichloride 1 ; 1,000 : i, glass tray containing used 
nozzles ; M, tray to hold used instruments ; N,N,N,N, solutions of silver nitrate , 0. minim 
graduate ; P, bottle containing powdered boric acid ; other bottles on this shelf contain car- 
bolic acid, nitric acid, etc. ; q, bottle holding three gallons boric acid, four-per-cent. solu- 
tion ; P, five-gallon bottle containing mercuric bichloride 1 : 1,000 (q and P have rubber 
tubes pending from them); S, Bernstein Company's office table; T, irrigating basins ; Z7, 
glass urinal ; "FT, pan for irrigation in recumbent posture. 

3 



3i THE IRRIGATION TREATMENT OF GONORRHCEA. 



VI. CONSTITUTIONAL AND ACCESSORY 
TREATMENT. 

Any conduct, food, or drink that increases the irritation of 
the inflamed region or regions in gonorrhoea must, as in inflam- 
mations of other parts, necessarily increase the disease, prolong 
its duration, and thwart the ultimate object of treatment. 

There is little difficulty in causing patients to submit to the 
necessary restrictions when they are made aware of the risks 
incurred by their infraction (see Chapter VII. " Complications ") . 
The constitutional and accessory treatment entails some restric- 
tions, which will be indicated here. 

Amusements. — The depressing influence which clap exercises 
upon most minds may be due to the consciousness of being 
affected with an unclean disease, to the deprivation of sexual 
intercourse, and to enforced abstinence from alcohol. This, how- 
ever, would not account for the depression so frequent in those 
who do not allow the presence of a clap, unless accompanied 
by painful symptoms, to interfere with their self -gratifications. 
The possible effect of gonococci toxins directly upon the nervous 
system may, when better understood, give the explanation. 

If a patient with gonorrhoea were to withdraw from all enter- 
tainments during the disease, he would necessarily brood over 
the cause of his ostracism and its consequences. This would 
accentuate the mental depression. He should therefore seek 
diversion, such as society, theatres, etc., offer, but most posi- 
tively avoid people, scenes, exhibitions, and literature that could 
evoke lubricious thoughts. 

Bathing. — There is no reason, during gonorrhoea, for absti- 
nence from the daily bath ; on the contrary, it is necessary for 
the purpose of maintaining the patient's resistance. But sev- 
eral precautions in bathing are absolutely imperative. Before 
bathing, the patient should urinate, dress the glans with cotton 
soaked in mercuric bichloride 1 : 6,000, or boric acid four per 
cent., and cover the entire penis with a well-fitting condom, to 
be worn throughout the bath. This is the only safe manner in 
which gonorrhceal pus can be prevented from mixing with the 
bathing water and possibly adhering to the sides of the tub, 



CONSTITUTIONAL AND ACCESSORY TREATMENT. 35 

with all the danger to the eyes of the patient, and to the eyes, 
vagina, or rectum of another who may use the bath-tub after him. 
While do one, even in health, will rely upon the care of servants 
to cleanse a bath after he used it, the gonorrhceic must be spe- 
cially cautious in this regard. It would never be an excess of 
conscientiousness if the patient scrubbed the entire bath-tub 
personally with brush and strong soap, using boiling water into 
which he has dissolved two ounces of corrosive sublimate, for a 
tub capacity of twenty-five gallons. Following this, the hot 
water should be allowed to run again until the tub is entirely 
filled, to rinse it after the scrubbing. Even those who live in 
bachelor apartments and have their individual baths should be 
instructed to do this for self-protection. 

After the bath the condom should be removed at once, and 
thrown into the water-closet or preferably burned. 

Bed. — The gonorrhceic patient should sleep on a hard mat- 
tress with light coverings, lest the heat of either provoke erec- 
tions, with their determination of blood to the inflamed region, 
and possibility of chordee. As erections are not likely to occur 
while the patient sleeps on his side, it will be well if he ties a 
towel around his abdomen with a hard knot immediately over 
the spine. Should he turn on to his back during sleep, the pres- 
sure of the knot will either awake him or cause him to return to 
his side without disturbing his sleep. 

Beverages. — With a view to diluting the urine so that it may 
prove less irritating to the urethra, diuretics and diluents of 
all kinds are advised. The only diluent of any value is pure 
water in very large quantities, as a gobletful (fl 3 vi.) every two 
hours or every hour. 

All alcoholic beverages must be strictly interdicted, unless 
the patient is in the habit of using them to such an extent that 
his appetite would suffer from the deprivation. Then a glass, 
or even two, of light claret may be allowed at meals. But beer, 
white wine, champagne, whiskey, and brandy must be positively 
forbidden. 

Carbonated drinks, such as vichy, seltzer, ginger ale, sarsa- 
parilla, soda water, and other beverages charged with carbonic 
acid gas, are much used by patients with gonorrhoea, under the 
prevailing impression that they are beneficent in the disease. 
This is a signal error, as all these drinks are genito-urinary 



36 THE IRRIGATION TREATMENT OP GONORRHOEA. 

irritants. The extent to which the damage caused by carbonated 
drinks can go is well shown in a case reported to the Deutsche 
niedicinische Gesellschaft by its president, Dr. H. G. Klotz, ' on 
March 6th, 1899. The patient, aged twenty-two, had been 
treated for gonorrhoea and stricture. Suddenly a white lump, 
resembling macerated chalk (" geschlemmte Kreide ") and some 
blood were ejected from the urethra, amidst violent pains radi- 
ating from the renal region. For some days the urine was 
heavily turbid and contained albumin. Chemically and micro- 
scopically phosphates were found, and the sediment contained 
various cocci and epithelial cells. The author assumes that 
phosphates had accumulated in and irritated the renal pelvis 
and calices in consequence of the patient's drinking large quantities 
of carbonated soda. The author shows that an accumulation 'per 
se so innocent as that of phosphates can produce inflammation 
of the kidney, if improperly treated or neglected. Such an 
acute nephritis can as readily proceed to chronic nephritis as 
can the renal inflammations due to other causes. 

Klotz relied mainly upon urotropin in this case, which was 
cured in the course of three weeks. 

This and many cases with a similar history may account for 
the large number of kidneys invaded and destroyed by gono- 
cocci, if they were perfectly healthy before the patient was the 
victim of clap. 

"Drinking away a Clap." — Many patients assure their phy- 
sician that they have known men with very acute gonorrhoea to 
drink heavily for a long time and thus cause the clap to disap- 
pear. Some will relate this as a personal experience in a pre- 
vious attack. This statement deserves all the allowance phy- 
sicians must make for the curious ideas that in some manner 
have forced themselves upon the laity. The fact remains that 
the patient who alleges that he " drank away " a previous clap, 
or honestly thinks he knows of others who performed this im- 
possible feat, is then under treatment and continues under it 
until he is well. Meanwhile he abstains from fantastic efforts 
to cure the disease with alcohol in any form. 

Exercise. — Unless the patient has fever, he should take 
sufficient exercise to keep himself in good condition. Walking, 

'Klotz-. "Phosphaturie und Pyelo- Nephritis." New Yorker niedicinische 
Monatschrift, October, 1899. 



CONSTITUTIONAL AND ACCESSORY TREATMENT. 37 

driving over smooth roads, rowing, and such outdoor sports as 
will give him gentle exercise are certainly recommendable, not 
only for their physical but also for their mental effect. 

Bicycling and horseback riding must be positively forbid- 
den during gonorrhoea, as they expose the testicles and pros- 
tate to vibration at least, or small concussions, if not severe 
injury, inviting extension of the disease to these organs. 

In this connection Prof. G Frank Lydston' says: 

"Cycling frequently produces hyperactivity of the sexual 
organs with resulting disposition to sexual excess and aggrava- 
tion of any pathological condition which may be present , . 
urethral and prostatic inflammation are often aggravated by 
bicycle riding. Kelapses of inflammatory troubles of the ure- 
thra, prostate, and bladder very often follow bicycling- I doubt 
whether inflammation may be produced de novo in individuals 
possessing a previously healthy genito-urinary apparatus. An 
exception might possibly be made in the case of individuals who 
ride that peculiar form of bicycle invented by the devil and 
dedicated to Eros— the bicycle built for two." 

Food. — If a patient with gonorrhoea has not a disturbing 
elevation of temperature, he certainly requires sufficient food to 
keep him as well nourished as possible, to aid him in resisting 
the microbic invasion. In this quest all articles difficult of 
digestion must be avoided, as must all food that for any reason 
disagrees with the patient. 

Some authors hold that if a patient with gonorrhoea were 
kept in bed on a very low diet, he would recover from the infec- 
tion without local treatment. I regret that I must confess hav- 
ing made the experiment, which each time resulted in abject 
failure. 

While complete rest in bed and low diet are absolutely neces- 
sary in the severe form of posterior gonorrhoea, they are useless 
without proper medication (see Chapter IV., "Acute Posterior 
Gonorrhoea"). 

When acute gonorrhoea is not accompanied by much eleva- 
tion of temperature, and when no complication obliges the pa- 
tient to remain in bed, this, together with reducing his food, 



'Lydston: "Athletics in their Relation to the Male Geni to-Urinary Or- 
gans." Medical Mirror, St. Louis, September, 1899. 



38 THE IRRIGATION TREATMENT OF GONORRHCEA. 

would supply means for reducing his resistance to the microbic 
invasion. 

Gin i3 mentioned separately because of the wide reputation 
it unjustly enjoys for beneficial effects in gonorrhoea. While it 
acts as a diuretic, it irritates the kidney directly and the rest of 
the genito-urinary apparatus as much or even more than any 
other alcoholic beverage. 

Suspensoky Bandages.— Their necessity in gonorrhoea is 
discussed under Epididymitis, page 55. 

Tobacco. — It is not shown at all that smoking or chewing 
tobacco exerts any unfavorable or favorable influence upon gon- 
orrhoea, unless the patient uses tobacco to a depressing extent. 
Then, naturally, its use must be curtailed. 



VII. COMPLICATIONS AND SEQUELiE OF 
GONORRHCEA. 

An acute gonorrhoea, if treated by properly conducted irriga- 
tions from the inception of the disease, does not become com- 
plicated. But patients with a first gonorrhoea, or those who 
have never been treated by irrigations, are not likely to come 
for treatment early, i.e., when the first swelling of the lips of 
the meatus presents, or shortly thereafter. Others, in whom 
irrigations have not been judiciously employed, may present 
complications. A final and very large class embraces those 
men who had gonorrhoeas before and, having been improperly 
treated, acquired conditions (strictures inter alia) which com- 
plicate the newly acquired disease. 

When urethral complications existed before the new gonor- 
rhoea, they cannot be diagnosed until the acute symptoms have 
been subjugated by irrigations, as the insertion of an instru- 
ment into an acutely inflamed urethra is never warranted. The 
only exception hereto may be in acute retention, when all other 
means have failed, and catheterization remains the sole refuge 
for emptying the bladder. 

For convenient reference, the most frequent complications of 
gonorrhoea are here placed in alphabetical order. 

Abscess, Follicular and Peri-urethral. — If the gonococci lim- 
ited their search for pabulum to the surface of the urethra, their 



COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 39 

progress, and that of the inflammation they produce, would ex- 
tend only backward. But they also invade the mucous follicles 
and gland ducts. When this occurs, as it very frequently does, 
the ringer passed along the lower surface of the urethra when 
exposed as for anterior irrigation (vide ante, Fig. 8, page 15) 
finds distinct nodulations. The glands and follicles are espe- 
cially well developed at the meatus, whence pus may be easily 
expressed. 

When swelling or inflammatory exudation occludes the ducts, 
the normal or catarrhal secretion of their glands is retained. 
The resultant pus pockets (follicular abscesses) are thus ex- 
plained. As the follicles are ordinarily most numerous in the 
anterior third of the pendulous portion, this is the most frequent 
site of these abscesses. They soon become distended with pus 
and then feel like shot of various sizes under the skin, which 
is normal in color and freely movable over the abscesses. 
Touching them sometimes causes quite sharp pain. While in 
this condition, the probability is that they will open into the 
urethra. When the abscesses terminate in this manner, the 
ducts that have been occluded become patulous again. 

When the follicular abscess does not terminate as just de- 
scribed, the skin over it becomes red and attached to the nodule. 
If not relieved by early incision it breaks down and the pus 
cavity is evacuated externally. The duct of the gland so de- 
stroyed is obliterated, and the abscess cavity heals by granula- 
tion. 

Sometimes quite an agglomeration of such follicular abscesses 
presents near the attachment of the frenum to the meatus. The 
frenum is then apt to become very ©edematous, entirely obliter- 
ating the normal depressions at its sides. The angry appear- 
ance of the region conveys the impression that the abscess must 
destroy or at least perforate the frenum or result in fistula. 
But after discharge of the pus, the abscesses ordinarily heal, 
the oedema subsides, and the ducts of the follicles remain closed ; 
consequently neither fistula nor destruction of the frenum re- 
sults. As,, however, either outcome is possible, the unaided 
breaking of these abscesses should not be awaited. 

A gummatous nodulation at the base of the frenum, usually 
painless, may be mistaken for follicular abscess, especially if 
the patient has forgotten, as sometimes in reality happens, that 



40 THE IRRIGATION TREATMENT OF GONORRHOEA, 

he ever had syphilis. If the tumor is gummatous, vigorous 
antiseptic dressings are decidedly contraindicated. Incision 
could produce only breaking down of the gumma, insuring per- 
haps large destruction of the penis. Therefore when such a 
gumma presents, nothing but mild antiseptic dressings should 
be employed, while remedial measures are administered con- 
stitutionally. 

As the mucous follicles at the frenum are walled by rather 
dense fibrous tissue, their abscess formation is circumscribed. 
Yet from any cause this fibrous envelope may give way and pro- 
duce extensive destruction and deformity of the glans. There- 
fore surgical intervention, as early as possible, is a wise and 
necessary precaution. Failure to employ it has occasionally 
been followed by such cicatricial contractions as to so distort 
the relation of the glans to the penis as to make erection ex- 
ceedingly painful and coitus impossible. 

The follicles at other parts of the urethra than those near 
the frenum have less connective- tissue protection. Therefore 
when they become involved their disease products are prone to 
invade the tissue of the corpora cavernosa penis and still more 
the corpus cavernosum urethral. Suppuration of the follicles 
here takes on the form of peri-urethral abscess. 

These abscesses around the urethra originate as folliculitis 
or adenitis. Their pain, tenderness, and swelling are greater 
and develop more rapidly. If the swelling urethra ward is more 
marked, the urinary stream is smaller than normal. Some- 
times, when the pain is greatest, the duct proves to be the point 
of least resistance. It will then suddenly give way and permit 
the pus to escape into the urethra. The pain then is arrested 
or very much mitigated, the tension about the swelling is re- 
duced, and the urine carries with it pus and blood. If the ab- 
scess cavity points forward, i.e., toward the meatus, it will 
probably heal rapidly. If, however, it has not this direction, 
urine may enter it and urinary infiltration with all its dangers 
may result, requiring rapid, free incision. Should the abscess 
open both within the urethra and through the skin, urinary 
fistula is the consequence. 

When a peri-urethral abscess first presents, gentle massage 
may cause its contents to overcome the swelling of the duct and 
restore its patulousness. When this fails, the enlarged glands 



COMPLICATIONS AND SEQUELS OF GONORRHOEA 41 

or follicles should be slit, curetted, and dressed with nosophen. 
The large amount of pus that then escapes seems utterly out of 
proportion to the size of the tumor. When the swelling is dif- 
fuse or painful, enveloping the penis in hot or cold antiseptic 
dressings may give relief. 

While it is true that many peri-urethral abscesses open spon- 
taneously, it is not well to rely upon this outcome; it is likely 
to result in an open sinus or fistula. When such spontaneous 
opening has occurred, permanent catheterization should be em- 
ployed as a safeguard against urinary infiltration. 

If unhealed follicular or peri-urethral abscess precedes an 
acute gonorrhoea, the dangers and difficulties of cure are very 
much enhanced. 

Adenitis (gonorrhoea!) — see Lymphadenitis. 

Adhesions (preputial) are often practically congenital. At 
all events many children sent to the specialist for circumcision 
are found to have the prepuce more or less firmly adherent to 
the glans. Concretions of smegma may harden and cause ulcer- 
ation of the delicate mucosa ; drops of urine may be retained in 
the preputial sac, decompose and irritate the tissues, and uri- 
nary salts may form calculi there. The constitutional conse- 
quences of adherent prepuce and the other conditions mentioned 
are well described by pediatrists. 

When an adult with adherent prepuce acquires gonorrhoea 
the case is practically incurable, unless the prepuce is immedi- 
ately detached from the glans. This is easily done with a stout, 
blunt probe, after injecting a four-per-cent. solution of cocaine 
into as much of the sac as can be reached by it. While the 
denudations so produced may threaten invasion of the organism, 
especially if the gonorrhoea depends upon a mixed infection, 
the chance of danger is far less than if the disease is allowed to 
continue because of the adhesions. After separating the pre- 
puce, readherence of the raw surface will be prevented by dress- 
ing the glans with absorbent cotton soaked in mercuric bichlo- 
ride, as described on page 16. When the orifice of the foreskin 
is too tight for the admission' of cotton, reformed adhesions 
should be broken up by passing the sterilized probe entirely 
about the glans, beneath the prepuce, before each irrigation. 
The lesions produced by this little operation ordinarily heal 
in about forty -eight hours, leaving a freely movable foreskin. 



42 THE IRRIGATION TREATMENT OF GONORRHOEA. 

Notwithstanding the favorable result, such patients should be 
circumcised as soon as they have recovered from gonorrhoea. 

When preputial adhesions result from gonorrhceal balano- 
posthitis, they should be treated as above outlined. As then 
the inflammatory process has usually much thickened the fore- 
skin, greater gentleness in the operation, if possible, is required. 
It may be well, in such a case, to keep the penis continually 
soaked for a day or two in hot bichloride solution 1 : 10,000 that 
the swelling may subside before separating the prepuce from the 
glans. In extreme cases it may be wise to remove the foreskin 
entirely if the above-mentioned measures cannot bo carried out. 

Stripping the prepuce beyond the glans to break up adhe- 
sions is exceedingly painful, unsurgical, and unnecessarily pro- 
longs the treatment. Moreover, it exposes the patient to the 
dangers of paraphimosis. 

Albuminuria. — The urine of a gonorrhceic always contains 
albumin as part of the pus it carries. When vesical tenesmus 
accompanies the disease, the urine shows more albumin than 
is accountable by the amount of pus present. The explanation 
of this excess of albumin that seems most reasonable has been 
mentioned on page 22. The treatment for this mechanical al- 
buminuria is touched upon under vesical tenesmus (page 27). 

Anemia. — When anaemia complicates a gonorrhoea, the pa- 
tient's vital resistance is reduced, the case prolonged, and inva- 
sion of other organs invited. Such a condition must be met by 
the appropriate constitutional remedies, in addition to irriga- 
tions. 

Balanitis and Balanoposthitis. — "Though gonococci seem 
to play no causative role in the production of balanitis, or in- 
flammation of the surface of the glans penis, this is a frequent 
complication of gonorrhoea" (White ^nd Martin). On the other 
hand balanitis, so frequently produced by uncleanliness, phi- 
mosis, or adhesions of the prepuce, may extend to the urethra 
evoking a discharge therefrom which symptomatically resembles 
gonorrhoea. The absence of gonococci from this discharge may 
prove the urethritis to be due to an infection from the balanitis. 

Most frequently, predisposition to inflammation of the 
mucous lining of the glans and foreskin is brought about by a 
very large or very dense or tight prepuce, or one with a small 
opening. The normal secretions are then retained causing 



COMPLICATIONS AND SEQUEL M OF GONORRHOEA. 43 

epithelial softening, and the apposed surfaces rub upon each 
other, producing denudations. When contagious material enters 
the preputial sac, it finds at least some of the region without its 
uppermost epithelial protection and therefore a good culture 
medium. 

Eheumatism, gout, and diabetes also predispose the patient 
to balanoposthitis. 

Traumatisms, even so slight as friction from the clothing, 
violent attempts at intercourse, and contact with irritating dis- 
charges may also cause balanoposthitis. 

Heat, some tickling or itching about the glans, provoking 
frequent erections, inaugurate inflammation of the mucous cover- 
ing of the glans or lining of the foreskin. This is usually asso- 
ciated with or quickly followed by redness and swelling of the 
preputial orifice. A little later a foul-smelling discharge, if not 
so copious as to escape unaided, can be pressed out of the 
orifice. If the prepuce can be stripped back, a thick, paste- 
like, irregularly lumpy secretion, mixed with liquid pus of a 
very putrid odor, is discovered. When the inflammation has 
existed some days, the mucous membrane of the glans may be 
eroded, occasionally in circular or irregular spots, grossly re- 
sembling chancre or chancroid. 

If neglected, the inflammation of the preputial sac is likely 
to cause immense swelling of the foreskin and glans. The 
oedema of the foreskin may go over into an erysipelatous red- 
dening, which may extend to thefroot of the penis. The lymph 
ducts may be involved. Inflammatory phimosis or paraphimosis 
may result. The pressure then exercised by the prepuce and the 
glans upon one another may produce gangrene of either or both. 

Even if such extreme results do not obtain, balanoposthitis 
may cause adhesions of the prepuce to the glans, rendering 
erection painful and coitus impossible. 

The first indication for treatment of balanitis and balano- 
posthitis is naturally in the removal of the cause. When the 
foreskin can be everted, the sac must be gently but thoroughly 
cleansed with cotton tampons soaked in hot bichloride solution 
1 : 3,000 or 1 : 4,000. Then nosophen is thinly strewn upon the 
exposed mucosa. A thin layer of absorbent cotton is placed 
about the glans, and the foreskin drawn into place again. Ac- 
cording to the severity of the case this may be repeated twice 



44 



THE IRRIGATION TREATMENT OF GONORRHOEA. 



or three times daily. Light cases, that seemed inveterate under 
other treatment, yield to the one just described very quickly, 
sometimes as soon as within forty-eight hours. 

When the disease has proceeded to such swelling of the pre- 
puce that it cannot be retracted or when it affects the sac of a 
tight or partially adherent prepuce, irrigations of the sac with 
potassic permanganate 1 : 2,000 or 1 : 3,000, twice or three times 
daily, will cause the inflammation to abate. 

When the prepuce is cedematous and very tender to the touch, 
the penis may be kept continuously wrapped in a hot bichloride 




Fig. 13.— Taylor's Phimosis Scissors. 



solution 1 : 10,000 until the swelling subsides sufficiently for 
more direct treatment. 

When the inguinal glands are enlarged in the presence of a 
very intense swelling of the foreskin, through which an indura- 
tion is felt, the surgeon may be justified in splitting the prepuce 
to expose and treat a possible phagedenic ulcer, which, if neg- 
lected, may destroy the glans or a great part of the penis. 

Under such circumstances, or when the patient is a diabetic, 
it is usual to slit the dorsal aspect of the prepuce, with a view 
to complete circumcision, after the acute inflammatory condi- 
tion has passed off. But this slitting, especially when the swell- 
ing and induration are great, does not expose the glans and 
the lining of the prepuce nearly as much as would be desirable. 
Therefore it is much better and more effective to cut both sides 
of the foreskin midway between the dorsum and the frenum, as 
proposed by Taylor. The scissors he devised for the purpose 
will be found the best instrument that can be used. When these 
scissors are not at hand they can be substituted by a grooved 
director to protect the glans and guide a stout curved bistoury 
to the coronary sulcus. 



COMPLICATIONS AND SEQUELS OF GONORRHOEA. 45 

The danger of infecting the so cut surfaces must be accepted 
as the risk preferable to the one of allowing the penis to be de- 
stroyed by an unknown ulcer. 

Immediate circumcision would be more desirable, but the 
incision that then encircles the penis would not be likely to 
unite by primary union. Even if general infection does not 
result, circumcision in such cases is prone to be followed by 
extensive sloughing, from whose destructive results the thermo- 
cautery even may not save the penis. 

Later on, when the primary condition has subsided, com- 
plete circumcision may be advantageously performed for cos- 
metic effect. 

Bladder, Inflammation of — see Cystitis. 

Bleeding— see Hemorrhage. 

"Blind" fistula, i.e., minute canals having their opening 
posteriorly from the meatus, may cause a gonorrhoea to be ex- 
ceedingly obstinate. If the inflammatory condition does not 
produce their obliteration, or if irrigations do not produce in 
them that general cedema which would make them an unfavor- 
able culture medium for gonococci, they continue to supply in- 
fection to the urethra. They may, in part, account for the five 
per cent, of failures in the irrigation treatment as collated by 
Goldberg (page 1). 

In obstinate cases they should be sought by means of the 
urethroscope and silver nitrate injected into them by Kollmann's 
syringe ; this failing they must be slit into the urethra or extir- 
pated. When such a fistula is very shallow and close to the 
meatus, it can usually be destroyed by electrolysis, performed 
under cocaine anaesthesia. 

Bubo — see Lymphadenitis. 

Cavernitis may complicate a yery mild gonorrhoea, when 
the urethral epithelial layer is subject to traumatism, admitting 
gonococci to the mucosa itself, to the submucous tissues, and 
through these to the corpora cavernosa penis or corpus caver- 
nosum urethrse. The traumatisms doing this damage may be 
strong injections destroying the epithelium, misuse of a sharp- 
pointed syringe, clumsiness in use of sharp irrigation nozzles, 
antrophores, sounds, or catheters. Violence in irrigations, per- 
formed by people who mistook their vocation when they en- 
tered the profession of Medicine, may cause rupture of the 



46 THE IRRIGATION TREATMENT OF GONORRHOEA. 

superficial layers of tlie urethral mucosa, with a consequent 
cavernitis. 

In the beginning of cavernitis the slight swelling may escape 
notice except during erection. Then, as the infiltration does 
not expand with the rest of the organ, it is bent or twisted 
toward the affected side. If the corpus cavernosum urethrse is 
affected, the penis is bent in the bow-form, familiarly called 
chordee (q. v. infra). 

If the invasion of the corpora cavernosa does not end in reso- 
lution, permanent infiltration or abscess forms. In the former 
case local circulation may be seriously impeded, with possibly 
consequent atrophy of the surrounding tissues. This may so 
deflect the penis during erection as to render coitus impossible. 

In the beginning of cavernitis rest, persistent hot or cold 
antiseptic applications, leeches to the perineum, low diet, pur- 
gatives, camphor or its monobromate, with or without opium, 
will give relief and aid resorption. In hyperacute cases, in 
which relief is not obtained by the above-mentioned measures, 
the infiltration may be punctured with fine needles to allow some 
blood to escape. The most exquisitely employed aseptic pre- 
cautions must be observed in this operation, which, as has been 
suggested above, is in place only as a last resort. In G.\e cases 
so treated immediate relief was obtained. One retained a slight 
contraction of the right corpus cavernosum, not enough, how- 
ever, to interfere with coitus. The others recovered entirely. 

In chronic cases galvanism, several times a week, one pole 
applied to the infiltration and the other to the opposite portion 
of the penis, may stimulate resorption. 

Sometimes general infiltration affects the three corpora cav- 
ernosa equally, producing persistent but painless priapism. 
One patient treated for subsequent stricture said that for three 
weeks he had been so affected ; all remedial efforts proved un- 
availing. He was sent on a sea voyage, and on the first day the 
erection subsided. As the physician who had treated this case 
had died, the exact facts could not be obtained. 

Oberlaender 1 cites a case of cavernitis reported by Kollmann 
which differs very much from those generally described. Im- 



' Oberlaender : "Die chronischen Erkrankungen der mannlichen Harn- 
rohre." Kliniscb.es Handbuch der Harn- und Sexual-Organe, Leipzig, 1894. 



COMPLICATIONS AND SEQUELS OF GONORRHOEA. 47 

mediately after the excision of a primary chancre on the pre- 
puce, preceded by an injection of cocaine, a small infiltration 
behind the glans appeared. It grew to the size of a bean, and 
as it became larger, it travelled several centimetres toward the 
scrotum in the course of a few months. Then it proceeded for- 
ward again, dividing into two parts. When so situated erections 
were disturbed ; once the penis was doubled into a decided right 
angle. Later on the infiltrate travelled to the peno-scrotal junc- 
ture, where it remained and became smaller, but could be dis- 
tinctly palpated four and one-half years after its first appearance. 
Gonorrhoea could never be proven in this case ; nor could this 
cavernitis be attributable to syphilis, as it was not affected by 
antisyphilitic treatment. The excision of the chancre did not 
prevent general infection. 

Chancroid, or chancre, or a mixed sore, may complicate gon- 
orrhoea. But even if either involves the meatus or the urethra, 
careful irrigations need not be omitted. 

Chordee, Chorda Venerea. — Da Costa, 1 in his admirable 
chapter on "Diseases of the Genito-urinary Organs," defines 
chordee as " a condition of painful erection in which the penis 
is markedly bent." The patients describe it as the sensation of 
a hot wire drawn through the penis, like the cord of a bow. 
This bending is naturally in the direction of that part of the 
penis which is rendered less elastic and therefore cannot take 
part in the general turgescence of erection. When the inflam- 
matory action penetrates the submucous tissues and from them 
into the trabeculse of the corpus spongiosum, its extensibility is 
naturally impaired. Keflex irritability provokes frequent erec- 
tions, and as the inflamed corpus spongiosum cannot swell and 
stretch with the rest of the organ, the penis is bent. In the 
bending intense pain is produced. The lymph exudation that 
follows this inflammatory condition fills the intratrabecular 
spaces, preventing their filling with blood during erection. 

The pain may become so intense that the patient in his des- 
peration may recall having heard of "breaking the chordee." 
This is accomplished by laying the penis on a flat surface, such 
as that of a table, and striking the curved organ with the fist or 
a book. One patient reported that he placed his penis on a win- 

1 Da Costa : A Manual of Modern Surgery, Saunders, Philadelphia, 1898. 



48 THE IRRIGATION TREATMENT OF GONORRH03A. 

dow ledge and violently pulled down the sash upon it. White 
and Martin (op. cit., p. 96) say that "at times patients have 
sought relief by intercourse. The results are nearly as disas- 
trous as those consequent on forcible breaking, at least one 
death being attributable thereto." 

Naturally, no physician would advocate the brutal violence 
above mentioned. It may cause laceration of the urethra, with 
possibly fatal haemorrhage, rupture, with extravasation of urine 
and death from urinary infection, laceration of the corpora cav- 
ernosa, and gangrene of the penis. Even if none of these super- 
vene and if no very heavy stricture result, the part of the penis 
anterior to the site of the infiltration may be cut off from enough 
blood supply to produce erection therein. 

In chordee, the treatment outlined under cavernitis may 
suffice. In very severe cases, persistently continued very hot 
sitz baths may be added. If these fail, it may be necessary to 
use opium or any of its derivatives to its full effect. 

Condylomata. — The fact that condylomata usually appear 
upon the genitals probably accounts for their being called vene- 
real warts. No proof, however, exists that they are due to vene- 
real infection. As they originate most frequently upon moist 
surfaces, such as the mucous membranes of parts of the male 
and female genitalia, the Germans call them Feuchtwarzen (moist 
warts). Through careless mispronunciation this easily becomes 
" Feigwarzen" whose translation "fig warts" has in some man- 
ner invaded the English language. It would require more than 
ordinary imagination to conceive any resemblance to fresh or 
dried figs in these warts, except perhaps when the latter have 
grown very large and their upper surface exposed to the air 
presents a dry, horny yellowish-brown color, with rough nodu- 
lar surfaces. 

Weichselbaum described a condylomatous excrescence as a 
"simple or branched papilla, built on the type of a skin or 
mucous papilla, and covered with epithelium of varying thick- 
ness. The connective tissue in these papillae is generally much 
richer in cells and vessels than -is the connective tissue of the 
base from which they spring. The epithelial covering can be 
materially thicker than that of the region from which it origi- 
nates, but ordinarily it has the usual character of the epithe- 
lium of the region. The papillomata proceed from the normal 



COMPLICATIONS AND SEQUELAE OF GONORRHOEA, 49 

papillae of the skin or mucosa, which enlarge; new formation of 
papillae also takes place." 

These moist or dry papillary overgrowths may be as small 
as pin points, or may reach almost any size. They may be 
discrete or confluent. They begin in the sulci at either side of 
the frenum and in the sulcus behind the corona with equal fre- 
quency. They less frequently originate on the posterior border 
of the glans, the orifice of the foreskin, and least frequently 
upon the lips of the meatus. They rarely appear within the 
urethra. 

Irritating discharges either of gonorrhoea or the disturbance 
set up by uncleanliness, secretion retained and deconrposed by 
a redundant or tight foreskin may cause these warts. Accord- 
ing to their growth, which often is very rapid, and according to 
whether or not they are compressed between foreskin and glans, 
they may assume a shape and color varying from those of a moist 
red raspberry to those of a yellowish-white cauliflower. They 
may also by pressure of the foreskin form long ridges " like a 
cock's comb" (White and Martin). 

When flat and macerated by free secretion or discharge, con- 
dylomata may be mistaken for mucous patches. When broad- 
ened by growth, they may suggest syphilitic warts. But when 
lues exists, the excrescences on the penis are not usually its 
only evidence, even if a history of syphilis is denied. 

A wart appearing on the penis after middle life should al- 
ways suggest the possibility of epithelioma, even if its sur- 
rounding tissues are not infiltrated and the inguinal glands not 
indurated. The presumed wart should at once be thoroughly 
extirpated and microscopically examined for purposes of prog- 
nosis. 

When condylomata proliferate upon the glans they may in- 
duce pressure gangrene of the foreskin. After the gangrenous 
part of the prepuce is cast off, the whole or part of the condylo- 
mata may prolapse through the space so produced. When warts 
grow upon the meatus they may interfere with urination and 
ejaculation. 

As uncleanliness and maceration of their seat are the cause 
of condylomata, so scrupulous cleanliness and dryness are the 
prime indications for treatment while they are still small, i.e., 
when they are but little more than hyaline spots. 
4 



50 THE IRRIGATION TREATMENT OF GONORRHOEA. 

When they are isolated and take on the accuminate form, 
cleansing, drying, and dusting with powdered savin acts as a 
direct specific. 1 But even when they are quite large, powdered 
savin is worth trying for a few days. It occasionally causes the 
warts to slough off with surprising rapidity, leaving a base that 
heals very soon. 

If the mass is large and heavy, it may be touched three 
times daily with ferric chloride. The surfaces so treated shrinji. 
The shrivelled portions may be curetted and the application 
repeated. By successive scrapings and applications of ferric 
chloride the base is eventually reached. This must be thor- 
oughly curetted and its bleeding arrested with cotton pledgets 
soaked in five-per-cent. solution of antipyrin. 

Exceedingly large and confluent warts may require removal 
by the knife. The base may then be curetted and cauterized, or 
after curetting, the wound edges brought together by sutures. 
Usually the bleeding is very copious. If it cannot be other- 
wise controlled it must be arrested by the actual cautery. 

Intra-urethral papillomata, when they do not materially re- 
duce the urethral calibre, can be removed through the urethro- 
scope tube. When their number and size prevent introduction 
of the tube, the first growth may be grasped through a meato- 
scope by means of a silk thread. This serves to draw the ure- 
thral mucosa gently forward sufficiently to expose the deeper 
growths, which then can be removed by ligature or the incan- 
descent snare. 

Cowperitis is of relatively infrequent occurrence. It may be 
due to aggravating an acute or chronic gonorrhoea by sexual 
intercourse, undue exercise, an untoward motion, or alcohol, by 
unskilled catheterization (i.e., traumatism from within), a fall, 
laceration or cut into the perineum (traumatism from without), 
"or as a consequence of retrostrictural dilatation, when all ducts 
are stretched and the mucosa is eroded and inflamed by stag- 
nated and alkaline urine " (Horowitz 2 ). 

Cowper's glands being situated between the two layers of the 
triangular ligament, and also being contained by the deep peri- 

1 Posner : Therapie der Harnkrankheiten, Berlin, 1895. 

2 Horowitz : " Die Krankheiten der Cowperschen Driisen. " Zuelzer and 
Oberlaender's Klinisclies Handbuch der Harn- und Sexual-Organe, vol. iii., 
Leipzig, 1804. 



COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 51 

neal fascia, their inflammatory swelling is necessarily limited. 
Their pressure upon these unyielding tissues not only produces 
intense pain, but also renders the disease externally unrecog- 
nizable until these envelopes have yielded. Moreover, as the 
ducts of Cowper's glands empty into the bulbous urethra, their 
involvement by gonorrhoea is easily comprehensible. Owing to 
the fact that the majority of cases of Cowperitis undergo resti- 
tution, it may be that they are oftener infected than is supposed 
and that the complication passes off unobserved. 

In the second or third week of neglected or improperlj- 
treated gonorrhoea, when the affection has invaded the posterior 
urethra, Cowperitis is most likely to become manifest. Then 
slight fever may set in, with a sensation of perineal discomfort. 
The mechanical impediment produces difficulty of urination and 
some pain on defecation. Shortly thereafter lancinating pains 
penetrate the region; these are aggravated by pressure upon 
the perineum, by sitting and walking. Even when lying down 
there is a sensation of perineal tension. The pains on evacu- 
ating the rectum and bladder increase, especially at the conclu- 
sion of urination, due to contraction about the inflamed gland 
by the transverse fibres of the compressor, as it forces out the 
last part of the urine. 

When but one gland is involved, as is ordinarily the case, it 
is evidenced by small, hard, exceedingly sensitive swelling at 
the corresponding side of the raphe about midway between the 
scrotum and the anus. This tumor may grow to the size of a 
chestnut, or become as large as a pigeon's egg, over which the 
skin is movable, while it retains its normal appearance. Palpa- 
tion of this tumor will not aid materially in diagnosis, as its 
painfulness prevents deep pressure. Digital pressure under 
anaesthesia would be unwise, as it might cause a rupture of the 
distended gland into the surrounding tissues with consequent 
danger of purulent, and possible subsequent urinary infiltration. 
The finger inserted into the rectum, its tip gently pressed forward 
between the external and internal sphincters, will reveal a round, 
smooth, hot, painful tumor below the prostate. When the tumor 
is found on one side of the mesian line, no doubt can obtain re- 
garding the diagnosis. When bilateral Cowperitis exists, and 
if there be much infiltration and distention of the surrounding 
tissues, the diagnosis is more difficult. 



52 THE IRRIGATION TREATMENT OF GONORRHOEA. 

The following will aid in the differentiation : 

"When Cowperitis set3 in, the urethral discharge is ordinarily 
much decreased or arrested entirely. 

Simple perineal abscess causes no compression inward or 
upward, and . consequently does not interfere with urination. 
Only when it is very large will it produce pain on defecation. 

Peri-urethral abscess of the bulb is invariably found cen- 
trally located about the raphe, and is situated nearer the scro- 
tum than is Cowperitis. 

Resolution ordinarily takes place within fourteen days under 
proper treatment. This consists in mild, gently administered 
washings of the anterior urethra, rest in bed, long-continued, 
very hot baths twice a day, saline laxatives to keep the stools 
soft, and a hot-water bag to the perineum. If the pain is very 
severe, morphine hypodermically may be required. When em- 
ployed, the needle should be as carefully sterilized as for use 
elsewhere, and care should be taken not to inject the solution 
into the tumor itself, lest suppuration be precipitated thereby. 

When, however, the inflammation is allowed to increase and 
the gland and periglandular tissues undergo suppuration, Cow- 
peritis assumes its grave form. One or more chills, fever, 
throbbing in the perineum show that pus has formed, even if 
fluctuation is not perceptible. If the case is then neglected the 
abscess may break into the perineum, the urethra, or the rec- 
tum. If it breaks toward the perineum it may dissect the skin 
from its underlying tissues, leaving it hanging like torn rags 
after perforation. Partial gangrene of the scrotum may also 
result. Such a spontaneous rupture may produce urethral and 
rectal fistulae, whose treatment is often very difficult. 

When such dangers are announced free incision should be 
immediately made. In making this incision it will be well to 
support the suppurating gland by the index finger in the rectum. 
After incision the cavity should be curetted or irrigated or both, 
and packed with iodoform gauze. It will be well to guard 
against urinary fistula, by keeping the urethra protected by 
means of permanent catheterization, until the abscess has suffi- 
ciently healed. 

Chronic Cowperitis shows itself as a hard, not very painful 
nodule at one side of the raphe, which when pressed upon dis- 
charges a turbid, milk-like secretion from the urethra. If it 



COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 53 

results after rupture of the abscess, this discharge issues from 
the perineum or into the rectum. 

It is always well to keep in mind that Cowper's glands may 
be the seat of a tuberculous infection and that therefore the dis- 
charge therefrom should be examined for the characteristic 
bacilli. 

Cystitis. — Inflammation of the bladder pre-existing, compli- 
cating or following gonorrhoea is too vast a subject to be more 
than merely outlined in a small sketch. That persons with cys- 
titis acquiring gonorrhoea can suffer its extension to the bladder 
is often proven. That gonococci can find a culture medium in 
a healthy bladder mucosa is denied. This negation seems to 
be borne out by the thousands of intravesical irrigations per- 
formed daily in acute anterior gonorrhoea. Despite all careful 
washings of the anterior urethra, the irrigation fluid must cer- 
tainly carry gonococci into the healthy bladder. Yet no cystitis 
ever results. It may be held that the gonococci so carried are 
brought into the bladder by an antiseptic solution. While this 
is true, no solution strong enough to destroy gonococci could be 
injected into the bladder without injuring its mucosa. On the 
other hand, cystitis has often been produced by inserting an in- 
strument through a urethra infected with gonorrhoea into the 
bladder. The bladder wall may have been bruised sufficiently 
thereby to injure its protecting epithelium. 

Whether gonorrhoea can invade the bladder by mere conti- 
nuity of surface is still one of the disputable questions. That 
gonococci can be carried beyond the strong compressor urethne 
is proven many times ; that they can traverse the weak sphinc- 
ter of the bladder is indubitable. But whether the healthy 
bladder epithelium ever can offer them food is not at all estab- 
lished, and from all experience is more than doubtful. 

When, however, the urethritis is of a mixed character, i.e., 
when the gonococcus is associated with other microbes, such as 
the bacterium coli commune, the bladder epithelium yielding 
to the latter may open the way for gonorrhoeal infection. 

Usually the region of the sphincter and of the trigone is the 
seat of such extension of inflammation, and has been aptly 
named urethrocystitis by Finger. The great rarity with which 
this inflammation extends to the rest of the bladder confirms 
the view of immunity of its lining epithelium to invasion by the 



54 THE IRRIGATION TREATMENT OF GONORRHOEA. 

gonococcus. Such invasion must be due to lesions produced by 
other bacteria. 

The symptoms of gonorrhoea! cystitis closely resemble those 
of posterior urethritis. The urgency and frequency of urina- 
tion are about the same. The patient also strains during and 
after ejecting small quantities of urine; he experiences the sen- 
sation as if the bladder still contained urine. In this urethro- 
cystitis, however, the patient is somewhat relieved while lying 
down, until the urine has filled the most dependent, not in- 
flamed, part of the bladder. This limit passed, the moment the 
urine touches the diseased region it re-establishes the urgency 
and the pain, which burns and scalds along the entire urethra. 
In this it differs from acute posterior urethritis, which is not 
relieved by any position, because the weak sphincter vesicae 
yields to slight urinary pressure and lets the fluid escape into 
the inflamed posterior urethra, where it sets up urgency, strain- 
ing, and pain after each micturition. The ejection of some 
drops of pure blood after each urination, with the other symp- 
toms just cited, is pathognomonic of posterior urethritis. 

The examination of the urine in portions, for differential 
diagnosis, is difficult in localized gonorrhoeal cystitis (urethro- 
cystitis) when frequent urination prevents sufficient accumu- 
lation within the bladder. In such case the bladder may be 
washed with a warm boric-acid solution until its outflow is 
clear, when a carefully sterilized soft catheter is inserted and 
fastened in place for an hour or two, if it can be tolerated so 
long. The catheter is clamped, or plugged with a "fausset" 
(spigot). If the urine that comes through it at the end of this 
time carries pus with it, the pus probably is from the bladder. 
The differentiation, however, is open to criticism. Even if 
pain from presence of the catheter be not so great as to prevent 
its use, there may be sufficient " back-flow " of pus from the 
posterior urethra to give the impression of cystitis, by the pus 
the accumulated urine carries. The only reliable method of 
differentiation is by means of the microscope. If the urine 
extruded shows a preponderance of bladder epithelium, and 
especially that of its middle or lower layers, the existence of 
cystitis is established beyond peradventure. 

Pus in the urine is easily recognized by adding to it satu- 
rated solution of caustic potash, and twirling the tube containing 



COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 55 

the mixture in as good an imitation of the centrifuge's action 
as can be done by the hand. The urine becomes clear, and the 
separated pus assumes a ropy, mucoid form. Donne, who de- 
vised this test, forcibly, albeit inelegantly, describes it as " rot- 
zig " (snotty) . Repugnant as is the adjective, none seems more 
apt for precise description. In cold weather this reaction may 
not be very prompt ; slightly warming the tube will then hasten 
it. If this does not then result, the turbidity is due to phos- 
phaturia, albuminuria, bacteruria, or an excess of epithelia. 

Another specimen of the same urine may be heated. If it 
grows more turbid over the flame, it shows that it contains 
either earthy phosphates or albumin. The addition of acetic 
acid will clear the urine if phosphates have rendered it turbid. 
If acetic acid does not change or even somewhat intensifies the 
turbidity, it proves the presence of albumin. The latter, how- 
ever, is always present with pus. 

When neither heating nor acidulation affects the urine, bac- 
teruria will usually be proven by the microscope. 

The treatment of gonorrhceal cystitis, which almost invari- 
ably presents itself as urethrocystitis, is practically the same as 
that advised for acute posterior urethritis and acute prostatitis. 

Divekticle, urethral— see Urethral Diverticulum. 

Epididymitis, or ORCHi-EProrDYMiTis, or both, like most of the 
other complications of gonorrhoea, may result from a precedent 
condition or from a new gonorrhoea. If preceding a new gonor- 
rhoea, inflammation of the epididymis or testicle or both may 
be due to traumatism, non-gonorrhceal infection, tuberculosis, 
or syphilis. 

As both the epididymis and testicle are frequently affected 
together, it is often impossible to decide whether one or the 
other is free from inflammation, and as the treatment of both 
ailments does not differ, there is ample warrant for considering 
them conjointly. 

The frequent difficulty, and often impossibility, of positively 
establishing that the testicle is not affected in gonorrhceal epi- 
didymitis may have led to the assumption that it limits itself 
to the epididymis. Further development of radiography of the 
soft tissues will probably soon lead to finer differentiation with 
consequent improvement in therapeutics. Carl Beck, of New 
York, made distinct pictures in which even the walls of the 



56 THE IRRIGATION TREATMENT OF GONORRHOEA. 

arteries were plainly radiographed in the living ; there is every 
reason, therefore, to hope for the outcome above expressed, with 
all its advantages to diagnosis and treatment. 

The pathological changes evidenced by post-mortem exami- 
nations and the experimental examinations made by Malassez 
and Terrillon (quoted by Finger 1 ) primarily show the testicle 
not to be involved. As, however, post-mortem changes may not 
have left evident serous infiltration or sanguinary engorgement, 
these observations cannot be taken as finally decisive. 

These authors found the epididymis enlarged, hypersemic, 
occasionally with circumscribed foci of pus; in old cases the 
epididymis was tough and calloused. The tunica vaginalis 
testis showed acute, serous, or serofibrinous vaginalitis. The 
vas deferens was often thickened. The microscope showed a 
catarrh of the seminal ducts and parvicellular infiltration of 
its connective-tissue envelope. The epithelium of the seminal 
ducts was turbid and swollen, deprived of its cilia ; in still older 
cases it was entirely absent, and the lumen of the canals filled 
only with spermatozoa, with parvicellular infiltration, or fibrous, 
calloused by connective-tissue change of the infiltrate, in ad- 
vanced cases. The changes in the vas deferens also begin with 
catarrh of the mucosa, to which parietal infiltration and thick- 
ening of the walls are added later on. 

It is held that epididymitis sets in most frequently during 
the third week after infection. Finger {op. cit.) collected the 
data of several authors, showing that in 1,015 gonorrhoeas, epi- 
didymitis appeared in the first week after infection in 46 cases ; 
second week in 157 ; third week in 132 ; fourth week in 191 ; fifth 
week in 132 ; sixth week in 64 ; seventh week in 44 ; eighth week 
in 61 ; from three to six months after in 117 ; from six to twelve 
months in 52 ; two years in 9 ; three years in 7 ; four years in 2 ; 
and seven years after in 1. 

The very long intervals between gonorrhoeal infection and 
epididymitis in some cases being evident from the above, its 
possibility must not be forgotten when a patient has epididymi- 
tis with a long passed history of clap. Then often unnecessary 
castration for presumed tuberculosis will be avoided. Senn 2 in 

1 Einger : " Die Hoden und Nebenhoden." Klinisches Handbuch der Harn- 
und Sexualorgane, vol. iii., 1894. 

2 Senn : Tuberculosis of the Genito-Urinary Organs, Saunders, 1897. 



COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 57 

one of his admirable works says : "Except in cases of acute dif- 
fuse miliary tuberculosis, the essential organ of generation in 
man is seldom the seat of primary tuberculosis." On the other 
hand, gonorrhceal epididymitis and traumatism are often the 
exciting causes of tuberculous disease of the testicle and epi- 
didymis. Senn 1 cites an illustrative case reported by Birch- 
Hirschfeld (Archivfur Heilkunde, 1871, Heft 6) : 

"A soldier, 24 years of age and in perfect health, contracted 
gonorrhoea which led to acute epididymitis. In the course of 
eight days he died of miliary tuberculosis. Miliary tuberculosis 
was found in the peritoneum, especially well marked at the in- 
ternal inguinal ring on the side of the affected testicle ; miliary 
tuberculosis of the pleurae, lungs, meninges, liver, spleen, and 
kidneys also existed; the epididymis was transformed into a 
cheesy mass. In the testicle itself numerous intercanalicular 
miliary tubercles were found, with a few cheesy nodules the size 
of a pea." 

In all cases of gonorrhoea the patient should wear a well- 
fitting suspensory bandage. I am not aware that any statistics 
exist showing the value of this bandage as a precautionary meas- 
ure. It seems, however, reasonable to assume that the scrotal 
contents, so supported, must be less exposed to traumatism 
than they would be if left to dangle by the often relaxed gen- 
eral condition of depressed vital tone. 

The selection of a suspensory bandage is not an unimportant 
matter. The form ordinarily dispensed, having no "back 
straps" to draw the bag perineumward, cuts the posterior 
aspect of the scrotum and pulls it into an abnormal position. 
The bag itself is of thick material in which the scrotal sweat 
cakes and hardens, irritating the skin, unless the bag is fre- 
quently washed. To avoid these defects, the suspensories should 
be of the forms sold as the " Syracuse " or " Army and Navy," or 
" Schnotter " suspensories. These have straps passing from the 
centre of the posterior boundary of the bag, between the thighs, 
over the nates, to be fastened to the belt. Eecently the bags 
have been made of a strong but very light linen mesh, which 
not only firmly holds the scrotum in place, but is also cool and 
comfortable. 

Gonorrhceal epididymitis, orchitis, or orcho-epididymitis is 



Op. cit., p. 54. 



58 THE IRRIGATION TREATMENT OF GONORRHOEA. 

usually ushered in by vague aching, sharp stitching, or continued 
neuralgic pains along the groin. Sometimes the pain is dis- 
tinctly denned as proceeding the length of the spermatic cord 
and dipping into the lower abdomen. The pain may be aggra- 
vated by standing or walking, and not relieved by sitting. Ex- 
amination of the cord shows the vas slightly enlarged and tender. 

Occasionally none of the pain or tenderness described above 
warns the patient or the physician of the approaching complica- 
tion. This fact emphasizes the need of daily examination. 
When thickening and slight tenderness of the vas on pressure 
between the ringers are found, active steps should be at once 
taken to abort the inflammation. 

In some cases, when the patient is not observant or when 
the physician is compelled to omit daily examinations, the com- 
plication appears to come on suddenly. A dragging pain is 
fixed in the testicle; the epididymis swells rapidly; the scrotum 
over it takes on oedema and soon becomes purplish. The pain 
nauseates the patient ; it may even lead to vomiting, as after a 
kick or blow upon the testicle. The urethral discharge usually 
is diminished or disappears during the acuity of inflammation 
of the scrotal contents. 

The epididymis is sensitive to touch, but this sensitiveness 
varies. In some cases it bears no relation at all to the increased 
size of the epididymis. A very slight enlargement of this gland 
may be exquisitely tender to the touch, while when it is so en- 
larged as almost to entirely envelop the testicle and exceed it 
materially in size, it may be rather roughly handled without 
producing pain. 

Not infrequently the tunica vaginalis becomes involved, with 
consequent serous effusion. The acute hydrocele so resulting 
may envelop the whole testicle in a large, tense swelling, mis- 
leading the inexperienced to a diagnosis of orchitis. The trans- 
lucency of the fluid and the enlarged epididymis behind the 
swelling will prevent this error. 

If the patient can walk, he spreads his bent legs wide apart, 
carries his body forward as if in continual desire to rest his 
hands upon his knees. When about to sit down, he grasps the 
chair and lets his body down slowly. Kising from the chair is 
accompanied by the same painful effort, as is any attempt to 
cross his knees. 



COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 59 

In the erect posture, the pain is increased. The weight 
of the swelling drags upon the spermatic veins, reducing their 
lumen ; the blood from the testicle cannot therefore return up- 
ward. The so augmented tension and pressure may cause the 
pain to be reflected to the perineum, rectum, back, bladder, 
down the thighs, abdomen, and the chest. When the reflex 
pains are as extensive as described, chills, fever, anxiety, and 
mental depression may become so marked as to overshadow the 
condition that provokes them. The abdomen may swell and 
become' very sensitive ; nausea, vomiting, and collapse may con- 
vey the idea that the patient has peritonitis. These reflex 
symptoms usually subside rapidly, and the swollen epididymis 
remains in evidence of their cause. 

In undescended testicle, to which inflammation is communi- 
cated, the patient may have all the symptoms of strangulated 
hernia. Emptiness of the scrotum, however, will prevent this 
mistake. 

With prompt and proper treatment, inflammation of the 
scrotal contents generally ends in resolution. The acute symp- 
toms usually subside in a week or ten days. 

When through neglect suppuration occurs, there are in- 
creased pain, chills, fever, sweating, and abscess is made evident 
by fluctuation. On opening it, the entire epididymis may pro- 
lapse out of the wound, especially if the operation has been un- 
duly delayed. The delay may also lead to destruction of the 
entire scrotal contents. 

The acute hydrocele resulting from acute epididymitis often 
becomes chronic. 

The most frequent result of epididymitis is the formation of 
a hard, painless nodule at its head or its tail. This nodule in 
no wise locally disturbs the patient; in some cases it rivets his 
attention and becomes the object of his continual thoughts, evok- 
ing most persistent neurasthenia. 

Treatment. — In a small number of cases the vas deferens 
shows the first sign of its carrying infection to the epididymis 
and possibly, through it, to the testicle. The funiculitis then 
evidences itself by pain and swelling in the inguinal region. 
Copious leeching of the region will then relieve the pain and in 
many cases prevent active involvement of the scrotal contents. 

If the epididymis is found swollen at the same time, and 



60 THE IRRIGATION TREATMENT OF GONORRHOEA. 

there be enough pain to warrant it, the patient should be kept 
in bed. A board or a sheet of tin, about the size of a cigar-box 
lid, should be cut so that it will lie comfortably upon the 
thighs and support the testicles. A three-inch gauze bandage 
is then wrapped smoothly entirely about this support to insure 
its softness. Over this a sheet of impermeable tissue is folded 
to fit neatly. 




Fig. 14.— Support for Testicles. 

Four or six layers of gauze eight by ten inches are then soaked 
in an antiseptic solution of five per cent, carbolic acid, 1 : 6,000 
bichloride or, if preferred lead and, opium lotion, and wrapped 
gently around the testicles. The solution may be applied hot 
or cold as may prove most grateful to the patient, and should 
be renewed every fifteen or twenty minutes. 

If the pain is not relieved in forty-eight hours, the case 
should be treated as described further on. 

When the funis is not at all or but slightly swollen, strap- 
ping the testicle will, in the majority of cases, afford instant, 
complete relief from pain and will cut short the disease. This 
treatment should, however, not be attempted unless the physician 
is thoroughly familiar with its technique and has the firmness 
to give the patient that short increase of pain which strapping 
inevitably entails. 

The technique of strapping a testicle as I employ it is a 
modification of Fricke's method: 

The patient lies on a table, his legs extended flat upon it and 
somewhat abducted; he or an assistant slightly supports the 
scrotum while the dressings are being prepared. Two strips 
are cut from a three or four inch gauze bandage, according to 



COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 



61 




the size of the swelling, and long enough to cover the scrotum 
from the perineum to the pubis. These strips are smeared with 
an ointment, slightly modified from that proposed by Casper, of 
Berlin, and composed of ichthyol 
2.5, guaiacol 5.0, ung. hydrarg. 
10, vaselin and lanolin, p. ae. ad 
30.0. The use of these strips 
renders shaving the scrotum un- 
necessary. 

The neck of the scrotum of 
the diseased side is then grasped 
between the left thumb and mid- 
dle or index finger, and with in- 
creasing pressure the testicle is 
forced to the bottom of the scro- 
tum. The compressing fingers 
are steadily, forcibly contracted 
until the region about the funis 
is reduced to its smallest possible 
calibre. Without releasing the 
grasp of the ringers a half-inch 
strip of strong adhesive plaster 

is firmly wrapped immediately below the fingers so tightly as to 
convey the impression that the funis might be strangulated 
thereby. This is the most painful part of the whole procedure. 
If not thoroughly done, the entire purpose of the strapping will 
be thwarted : the patient will experience no relief, the case will 
be aggravated, the scrotum injured and its contents exposed to 
abscess formation. Cases are not rare in which physicians, 
guided more by sympathy for their patients than by steadfast- 
ness of purpose, have strapped the swelling so that the testicle 
was forced up toward or almost into the inguinal ring and the 
epididymis away from the testicle. 

After the first strip of adhesive plaster (which I think may 
be properly called the " choker ") is firmly applied, the superficial 
veins of the scrotum will for a moment enlarge and stand as 
blue, more or less tortuous strings beneath the skin. One of 
the gauze strips smeared with the Casper ointment is firmly and 
smoothly laid from the posterior neck of the swelling to its an- 
terior aspect, and the second strip is similarly applied at right 



Fig. 15. 



The First Strip of Adhesive 
Plaster. 



62 



THE IRRIGATION TREATMENT OF GONORRHOEA. 



angles to the first. A second " choker " about three to four 
inches wide is now firmly wrapped around the root of the tumor 
covering the first " choker " and holding the four ends of the 
gauze strips in place. Then an adhesive strip half an inch wide 
and of sufficient length, is firmly attached to the centre of the 
posterior (perineal) aspect of the choker, tightly drawn over 
the testicle and attached to the centre of the anterior part of 
the choker. A second strip is similarly placed from the choker 
at the external surface of the scrotum to the mesian surface, at 

right angles to the first strip. 
A third strip is attached to the 
choker, immediately adjoining 
and slightly overlapping the 
second strip's entire course. 
Successive strips are placed in the 
same manner until the entire tes- 
ticle is firmly encased. 

It will be found necessary to 
heat thoroughly each strip and to 
apply it as hot as it can be borne 
by the patient, to secure its ad- 
hesion to the grease that oozes 
through the gauze. It will also 
be convenient to apply a new 
choker after each three or four 
longitudinal strips are applied. 
All attention should be di- 
rected to applying the strips smoothly, and with as firm and 
even pressure as possible. 

After the last longitudinal strip is applied, the whole dress- 
ing should be reinforced by a final choker about six inches 
long. Two or three turns of the choker are made about the 
neck of the tumor, the remaining strip is made to envelop the 
other longitudinal strips by interrupted spiral turns, returning 
to the neck. 

The projecting ends of the adhesive plaster about the neck 
of the scrotum are then cut off closely above the choker; the 
projecting ends of the gauze are also trimmed but allowed to 
extend about one-eighth of an inch above the choker, to protect 
the skin from erosions that otherwise would be likely to result. 




Fig. 16.— Testicle Strapped. 



COMPLICATIONS AND SEQUELJE OF GONORRHOEA. 63 

Before the patient rises, a large suspensory bandage with 
back-straps is firmly applied, after enveloping the whole testicle 
in a layer of cotton. Absorbent cotton having lost its resiliency 
in being prepared, should not be used for this purpose. 

The whole procedure, from placing the patient on the table 
to buckling the suspensory bandage, should not occupy over five 
minutes; the increased pain caused by applying the first choker 
should not, with ordinary skill, extend over ten seconds, the 
other manipulations should be comparatively painless. 

After the testicle is drawn as closely as possible to the pubis 
by the suspensory bandage, the patient is told to arise. If all 
parts of the work have been properly performed, it will be 
found that the patient can stand upright; that he can, wheal 
holding his heels and toes together, take up a small object lying 
immediately in front of his toes ; that he can stand, walk, turn 
rapidly, sit down, get up, cross his legs absolutely without pain 
and with no sensation about his genitals further than the feeling 
of some bulk between his legs, which, however, is but slightly 
or not at all uncomfortable. 

The exhilaration produced by the sudden cessation of local 
and reflex pains and the stopping of all constitutional effects 
thereof make the patient exceedingly willing to return in forty- 
eight hours for a second strapping. Usually the longitudinal 
straps will then be found loosely encasing the scrotum. A 
grooved director passed under the choker into the space between 
the scrotum and the plaster strips serves as a guide for strong 
scissors to cut the choker at the centre of its anterior aspect. 
The hair to which it is attached should be cut through, care be- 
ing taken not to snip the skin. When all the hairs are cut, pass 
the scissors through the anterior aspect of the entire casing, 
which can then be easily removed. The swelling will then be 
found reduced to one-third or one-fifth of its former size. If 
any excoriations have resulted from defects in the dressing, they 
should be dusted with nosophen and cotton packed into a snugly 
fitting suspensory bandage applied over it. If no excoriations 
have resulted, and especially if some tenderness still remains, 
the strapping should be reapplied and repeated every forty-eight 
hours. Some cases may require as many as four such strap- 
pings to reduce the inflammation to a subacute state, which 
then may be treated by applications of the Casper ointment on 



64 THE IRRIGATION TREATMENT OF GONORRHOEA. 

gauze strips twice daily. These strips should then be covered 
by a thick layer of cotton and impermeable tissue over the cot- 
ton, all held firmly in place by a well-fitting suspensory bandage. 

In some cases, having reached this stage, resorption of the 
swelling seems to be hastened by galvanism employed every 
second day. At the first seance the moistened negative elec- 
trode may be applied to the scrotum and the positive to the 
thigh. The seance may last five minutes and two milliamperes 
be employed. At the second seance the poles should be change'd, 
the time lengthened to six minutes and the current increased 
to three milliamperes. At each subsequent seance the poles 
should be changed, the application extended one minute and the 
amperage increased one milliampere. The use of galvanism 
should not be carried to a painful degree and the site of applica- 
tion of the positive pole, while kept firmly applied, should be 
continually moved to prevent excoriations. 

Sometimes the patient's timidity or the physician's lack of 
fortiter in re (never incompatible with suaviter in modo) prevents 
strapping the testicle in the class of cases cited. Then the 
indications for rest, elevation, warmth, and moisture can be 
approximately attained by the use of specially constructed sus- 
pensories. These were first suggested by Horand, and sub- 
sequently modified by Langlebert, von Zeissl, Casper, Falk- 
son, Letzel, White and Martin, and others. They differ from 
suspensory bandages mentioned before, in being much larger, 
stronger, and adjustable not only in the body and perineal straps, 
but also in having adjustable scrotal bags. Their cost is, how- 
ever, high. In cases in which the bandages mentioned before 
will not suffice, they certainly are serviceable. They are em- 
ployed as was directed for their use after strapping. 

A substitute for strapping and suspensories is devised by 
Karl Gerson, 1 of Berlin, who suggested the use of scrotal ele- 
vating strips. 2 These are strong elastic adhesive strips an inch 
wide, with one margin softly fringed. The end of the bandage 
has two small linen tapes. For use the scrotum is grasped be- 

1 Gerson : "Elastische Pflaster-Suspensionsbinden." Dermatologische 
Centralblatter, Heft iv., 1897 ; Berliner klinische Wochenschrift, No. 3, 1898. 

2 The words "scrotal elevating strips" are an intentional mistranslation 
of the author's "Suspensionsbinden," which in a literal version would cause 
confusion with the accepted English designation of suspensory bandages. 



COMPLICATIONS AND SEQUELS OF GONORRHOEA. 65 

low, and by compressing the sac, its contents are forced upward 
to as near the inguinal ring as possible. The bandage, which 
readily adheres to the scrotum, is tightly w r ound about it, with 
the fringed edge upward, to prevent abrasion. When the whole 
is wrapped about the emptied scrotum, it is firmly tied by the 
linen tapes. This leaves a part of the emptied scrotum project- 
ing below the bandage. The ease with which this manner of 
treating epididymitis can be employed, and the facility with 
which the patient can reduce its pressure, should it become too 
strong, are decided arguments in its favor. And indeed, in 
many cases (perhaps fifty per cent.) it acts quite satisfactorily. 
In some, however, the pain becomes so severe as to compel its 
removal, and in others it produces no appreciable effect. 

In exceptionally severe cases of epididymitis or orcho-epi- 
didymitis, or when the patient cannot bear even a touch of the 
inflamed scrotal contents, and when the treatment described on 
page 59 will not afford relief, tobacco poultices will assuage 
the suffering. These are made of equal parts of common smok- 
ing tobacco and ground flaxseed, boiled together and applied as 
hot as can be comfortably borne. As soon as such a poultice 
begins to cool, a fresh one should be applied. At night they 
ma}^ be substituted by the Casper ointment. 

While the inflammation is at its height, some authors still 
recommend crushed ice directly applied or used in an ice-bag. 
No relief is obtained by this treatment, which seems to increase 
the danger of abscess. It may be a mere coincidence that in 
every case I saw of loss of the testicle from gonorrhceal invasion 
of the scrotal contents, ice had been employed during epididy- 
mitis. 

It is ordinarily held that from the very onset of epididymitis 
treatment of the urethra should be stopped. This idea is prob- 
ably due to the usual diminution or entire arrest of the discharge 
when epididymitis begins. But in practice it is found that 
when the physician desists from treating the urethra during 
epididymitis, its subsidence is followed by a return of the dis- 
charge, usually far in excess of the original condition ; while if 
irrigations are persistently continued despite the epididymitis, 
recurrence of the severe symptoms of gonorrhoea does not take 
place. 

Epispadias and Hypospadias, when not so deforming the penis 
5 



66 THE IRRIGATION TREATMENT OF GONORRHOEA. 

as to make coitus impossible, are prone to interfere materially 
with successful irrigations. It is remarkable that men with 
very markedly deformed penes seek to gratify the genesic im- 
pulse. Their large exposure of mucous membrane makes them 
liable to more ready infection, and in these deformities, the in- 
genuity of the physician is often taxed for the successful em- 
ployment of remedial measures. Owing to sacculations and 
deviations produced by these deformities, gonorrhoea, despite 
the best directed treatment, is prone to go over into chronicity. 
The case then is not likely to be finally cured before the urethra 
is restored by plastic operation. 

Epithelium in the Urine.— The only epithelium found in 
normal male urine comes from the bladder. Louis Heitzmann, l 
following the principles laid down by the lamented Carl Heitz- 
mann, asserts that in addition to other microscopic evidences, 
the kind of epithelium found in the urine points out the region 
of the pathological process going on in the genito-urinary tract. 
Fantastic as this is asserted to be, I have almost daily evidence 
of the parallelism between microscopical and clinical diagnosis 
and always find it a decided aid. The details of the character- 
istics of the various epithelia, their application to diagnosis, 
would lead beyond the scope of this little book. Moreover, 
they are described by Heitzmann so fully as, in the light of our 
present knowledge, cannot be improved. 

I would like to add an important fact to his description of the 
epithelia found in the urine of stricture cases, even when a path- 
ological coarctation presents no other evidence of its presence. 
The urethral epithelia, then, have among them some thinned 
scales, with smoothed or faint nuclei and some without nuclei. 
These variations prove that stricture is forming and persists as 
long as they are present. The case must then be treated by di- 
latations and irrigations, as detailed under chronic gonorrhoea. 

Eye, Gonorrhceal inflammation of — see Ophthalmia, gonor- 
rhceal. 

Eig- Warts — see Condylomata. 

Fistula, urethral. Whether congenital or the result of peri- 
urethral abscess or of urethral rupture from stricture, a urethral 



1 Heitzmann : Urinary Analysis and Diagnosis, William Wood & Co., 
1899. 



COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 67 

fistula is not likely to render irrigation especially difficult, un- 
less the fistula is very large. If situated in the anterior ure- 
thra, it can ordinarily be covered by the finger during irriga- 
tion and evacuation of the bladder, when intravesical washings 
are employed. In that case it will be well to have the patient 
let some of the irrigation fluid pass through the fistula, so that 
its lining may receive antigonorrhceal treatment at the same 
time. Perineal fistulse do not usually offer much hindrance to ir- 
rigations. If, however, they do, on account of large dimensions, 
the patient can be instructed to hold them closed during irri- 
gation. 

"Floateks," in the urine. Macroscopically visible sub- 
stances carried from the urethra by the urine are among the 
numerous genito-urinary subjects that still merit much detailed 
study. Many eminent authors have made painstaking researches 
regarding them ; yet, until more precise devices and methods are 
employed, " floaters " in the urine will remain but partially un- 
derstood as regards their origin and special pathological signi- 
ficance. 

Their importance is well brought into relief by Guiard : 1 

" It is safe to say with Fiirbringer that the abnormal products 
contained in the first portion of the urine represent a more 
constant symptom of goutte militaire (morning drop) than the 
drop itself." 

These objects carried in the urine are usually spoken of as 
filaments or clap threads (Tripperfaden) without description of 
any distinctions between their forms. 

With a view to a clinical outline of their study I submit the 
generic term "floaters" for all these objects, fully conscious of 
its incompleteness, as it does not describe those, composed 
essentially of pus, which sink: to the bottom of the glass con- 
taining fresh urine. 

Koughly it may be said that these floaters differ in size, 
transparency, consistence, and conduct, according to the sever- 
ity of the disease, its chronicity, and the progress of treatment. 
These relations, however, are by no means firmly established. 

In studying these floaters, it must be remembered that there 
are floaters which have no relation whatever to disease. These 

1 Guiard : Les Urethrites chroniques, Rueff, Paris, 1398. 



68 



THE IRRIGATION TREATMENT OF GONORRHCEA. 







MPi* 



m 



i j 



\.% 



m§KhM 

mrnnM 






M»'#^!i 



MM 

wfi i-M 



\-sn'\: 



I have been called normal mucous filaments by Guy on. 1 The 
first urine passed after a night's rest, during which the secre- 
tions of the mucosa and its glands have not been washed away, 
carries with it a long, wavy filament. At spots it is rolled upon 
itself. It is transparent, occasionally encloses minute air bub- 
bles, whitish spots and streaks. It remains coherent on shak- 
ing the tube and sinks very 
:,-:; j slowly below the surface of the 

urine. Its coherence is still 
more manifest when grasped 
by forceps or fished by means 
of a needle; when withdrawn 
from the urine it stretches into 
great length as it is held sus- 
pended. 

In consistence this normal 
filament suggests the discharge 
that comes from the prostate, 
in that it can be dragged about 
upon a cover glass, maintain- 
ing its tenuousness for a long 
time. When allowed to rest, 
it shows a tendency to form a 
colorless, amorphous heap. 
As it dries very slowly, its 
preparation for the microscope 
is quite tedious. Endeavors 
to spread it with the platinum 
loop result in uneven masses 
interspersed with hard lumps. 
It is therefore best to press it between cover glasses while 
moving them about upon each other until an even smear is ob- 
tained. Even then, on separating the cover glasses, to let the 
specimen dry before flaming, its coherence is so great that it is 
likely again to run together into lumps. 

The specimen properly spread, stains best with alkaline 
methylene blue. For fine distinction this solution should not 







Fig. 17.— Normal Mucous Filament, from a 
healthy man, who never had urethritis. 
First morning urination. The mucous fila- 
ment holds leucocytes and epithelia in se- 
ries. X 300 diameters. (From Guyon: 
" Voies Urinaires," vol. ii., page 363.) 



'Guyon: Lecons cliniques sur les Maladies des Voies urinaires, tome 
premier, Bailliere, Paris, 1894. 



COMPLICATIONS AND SEQUELS OF GONORRHOEA. 69 

be over two per cent, and left in contact with the specimen for 
five minutes before washing it off. 

On examination this specimen is found to contain : 

Mucous threads and bands with a tendency to curl; their 
meshes hold, isolated, in small groups or in rows : 

Urethral flat epithlia with small nuclei ; 

Polyhedric or rounded epithelia with large nuclei ; 

Leucocytes, often in abundance. 

The normal filament never has micro-organisms of any kind, 
not even the bacteria of the normal urethra. These bacteria are 
found in secretion taken from the meatus, lying amidst the large 
epithelial cells. 

Not infrequently a healthy man learns that urethral filaments 
are evidence of disease. Unless the physician informs himself 
thoroughly of the appearance and other characteristics of the 
normal filament, and uses his knowledge to reassure his patient, 
the latter can develop most obstinate neurasthenia. If not con- 
vinced of the innocuousness of these normal filaments, he may 
get into the hands of quacks, who by maltreating the healthy 
urethra with injections or sounds, will set up an irritative ure- 
thritis with stricture or other complications in consequence. 

The dimensions and shapes of pathological floaters in the urine 
differ according to the severity of the disease, its duration, and 
the results of treatment. These differences are subject to most 
marked variations. With a view to establishing a basis of re- 
cording cases, and consequently their more detailed study, I 
submit the following classification : 

Shreds, coarse, large, medium, small, 
fine, 

Filaments, coarse, long, medium, short, 
fine, 

Flakes, coarse and fine. 

Granules, coarse and fine. 

In offering the above, concise descriptive terminology is 
the sole object. It would be remiss to omit from this list the 
comma filaments, which, ^according to Furbringer and Finger, 
are moulded to the comma shape within the prostatic duct in 
a diseased condition. When found, they usually are emitted 
with the last drops of urine. 

The conduct and coherence of pathological floaters bear no re- 



70 THE IRRIGATION TREATMENT OF GONORRHOEA. 

lation to their dimensions, nor have they as yet an established 
position in diagnosis. Guy on (op. cit.), however, advises re- 
taining the designations of purulent, muco-purulent, and mucous 
floaters as clinical definitions. 

Purulent floaters are short, multiple, opaque, friable, are 
easily broken up by shaking the urine, which they render 
turbid. They sink quickly (drop) to the bottom of the glass 
containing the urine. 

Muco-purulent floaters are often single, long, knotted; some- 
times one of their ends is rolled upon itself forming a sort of 
head. They look grayish-white and have opaque dots or stripes, 
held together by a transparent substance. They float toward 
the top or middle of the urine, and cohere almost as much as 
the normal filament when withdrawn for examination. 

Mucous floaters appear as do those of a muco-purulent char- 
acter. They differ, however, by remaining at or near the top 
of the urine column and in being almost entirely transparent. 

The conduct of these floaters conveys the thought that there 
exists a variance in their specific gravity — mucus being lighter 
than urine and the floaters proportionately heavier — in accord 
with the amount of pus they contain. Their histological and 
bacteriological elements also contribute to the floating or sink- 
ing of the floaters. For their study the reader is referred to 
works on these subjects. One that embodies the most recent 
views is by Louis Heitzmann, 1 whose practical value for pur- 
poses of diagnosis is beyond calculation. 

The examination of floaters, both macroscopic and micro- 
scopic, must be made from urine passed in the physician's office. 
For this purpose the urine brought in a bottle is worthless, as 
all floaters dissolve in a few hours. 

Under appropriate treatment, the shreds soon become broken 
up into flakes, the long filaments into shorter ones, and as the 
disease nears its end, all floaters become converted into granules. 
These changes will be more fully discussed under the treatment 
of chronic gonorrhoea. 

Folliculitis— see Abscess, follicular and peri-urethral. 

Foreign bodies in the urethra may complicate and aggravate 
gonorrhoea. They may be due to bodies inserted into the ure- 

1 Heitzmann : Urinary Analysis and Diagnosis by Microscopic and 
Chemical Examination, William Wood & Co., 1899. 



COMPLICATIONS AND SEQUELAE OF GONORRHOEA. Yl 

thra, as has been done in attempts to alleviate itching or tick- 
ling, for masturbatory purpose, or by instruments breaking off 
when introduced for therapeutic objects. Of the articles in- 
serted to allay itching or cause ejaculation, or broken off dur- 
ing surgical procedures, Englisch * mentions pins, bits of wood, 
twigs, grasses, roots, sponges, pipe stems, forks, catheters, cau- 
tery-carriers, pieces of forceps, etc. 

Concretions formed above, or fragments left in the bladder 
after lithotripsy may be carried to the urethra and be pinned 
fast there by their sharp points penetrating the mucosa. 

Foreign bodies (stones) may also form within the normal 
urethra ; they then are usually located in the fossa, rarely within 
the bulb. They may also be deposited in congenital or acquired 
diverticula or fistulae. They then usually are uric-acid stones. 

Foreign bodies inserted or formed in the urethra may be 
carried upward by its motions and those of the bladder. The 
lengthenings and shortenings of the penis under varying emo- 
tions may mechanically explain this inward progress. This, 
of course, is interfered with when the foreign body is sharp or 
rough, causing its ingression into a consequent adhesion to the 
urethral wall. 

A foreign body causes pain and the other inflammatory 
symptoms or an increase thereof, when these existed before its 
introduction. Efforts at urination, if the body is large, result 
in forcible distention of the urethra behind it, while the urine 
dribbles or drops from the meatus. If the body is very large 
or not promptly removed, retention may result, as may also 
abscess or extensive pockets of the urethra. 

Palpation reveals the location of the foreign body. Swelling 
about it may deceive the fingers regarding its size and character. 

If unduly left in the urethra, the urinary salts may form con- 
cretions about the foreign body. 

The sudden establishment of localized pain within the urethra, 
besides the other disturbances, direct attention to the possi- 
bility of a foreign body having been introduced, although the 
fact may be strenuously denied by the patient. This is the 
only circumstance in which urethroscopy is justifiable in acute 

1 Englisch : " Die chirurgischhen Krankheiten der mannlichen Harnrohre." 
Zuelzer and Oberlaender's Klinisches Handbuch der Harn- und Sexualor- 
gane, vol. iii., Vogel, Leipzig, 1894. 



72 THE IRRIGATION TREATMENT OF GONORRHOEA. 

gonorrhoea. The pain may be so severe as to require cocaine or 
encaine before a tube can be introduced to the site of the foreign 
body. Great care must be exercised to prevent the substance 
from being thrust farther into the urethra by the obturator. If 
it can be grasped through the tube by the Guy on urethral for- 
ceps, a dull curette, Guyon's hood or an instrument improvised 
for the purpose to cover the special needs of the case, it may be 
withdrawn with or through the tube, if their relative sizes per- 
mit. Whenever a rough or sharp body can be drawn through 
the tube, this method is certainly preferable, as thus the ure- 
thra is protected from additional injuries. When the body is 
too large to pass through the urethroscopic tube, it must bo 
removed by the most suitable of the many instruments devised 
for the purpose. When it is smooth and located in the pendu- 
lous portion, it may be pressed out of the urethra by careful 
manipulation. If, as occasionally happens, a man inserts a hair- 
pin or a hat-pin into the urethra, their points will bo found 
presenting forward. Efforts at removal are likely to cause ex- 
tensive gathering and penetration of the mucous folds. It will 
be well, to prevent such additional injury of whose extent the 
surgeon cannot judge at the time, to cause the points of such an 
instrument to penetrate the urethra at the centre of its floor 
and to turn the object by the projecting part so that its head 
presents forward. Then holding the projection firmly with 
strong forceps, the penis is stripped backward to cause the head 
to project from the meatus, so that it can be grasped by another 
forceps and withdrawn. It is better to thus risk a urethral 
fistula than to produce internal injuries of the urinary channel. 

The surgeon's ingeniousness is often severely taxed for the 
removal of stones formed in the urethra. They may be con- 
tained there for a long time without producing any special dis- 
turbance. Slow or sudden accretions may, however, establish 
increasing inflammatory symptoms, with local swelling, urinary 
infiltration, formation of abscesses or diverticulse, incontinence, 
chills, fever, pain at the site of the concretion or radiating pains 
through the penis. If not removed, nature may throw out the 
stone through extensive ulceration, producing large urinary 
fistulse which are difficult and sometimes impossible to repair. 
If the stone or stones so formed are left in the urethra, the pa- 
tient's life is in danger from sepsis. 



COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 73 

If the stone cannot be removed through the urethra, external 
urethrotomy over it must be performed as soon as possible. 

Frenum, short or rigid. While extreme degrees of this de- 
formity may render erection painful and intromission impossi- 
ble, it does not safeguard the patient from acquiring gonorrhoea. 
It offers no material interference with irrigations ; still, while the 
patient is under treatment, it may be well to slit the frenum to 
correct the deformity. In case of a timorous person, the little 
operation may be preceded by freezing the frenum with ethyl 
chloride. The glans is turned back, a narrow straight bistoury 
or tenotome passed through its base and the frenum cut from 
within outward. The cut may be dressed with iodoform or 
nosophen gauze and a light bandage applied to keep the fore- 
skin retracted and prevent coaptation of the cut extremities. 

Funiculitis. — Inflammation of the spermatic cord may 
manifest itself while the vas carries infection from posterior 
urethritis to the epididymis (see Epididymitis) or may in- 
dependently complicate gonorrhoea especially by rheumatic 
phlebitis. It may appear in the form of serous funiculitis 
(acute diffuse hydrocele of the cord) or of phlegmonous funicu- 
litis. The former shows itself as a roundish, sausage-like swell- 
ing along the cord, which is translucent and pits on pressure. 
Phlegmonous funiculitis manifests itself in the same shape, but 
it is not translucent and is very tender to pressure. From the 
acuity of the symptoms it may simulate strangulated hernia. 
It is the more dangerous form, as it may extend into the peri- 
toneum. 

Acute funiculitis in either form is treated as laid down under 
the lighter form of epididymitis. If the manifestations are so 
severe that the testicle is threatened, the funis should be incised 
and drained. 

Genekal Gonorehceal Infection. — Some of the complica- 
tions mentioned here can have their explanation only in con- 
veyance of gonococci through the circulation. P. Colombini ' 
reports a case which signally illustrates this : 

A mechanic, aged 28, had acute gonorrhoea ; in two weeks he 

Colombini : "Bakteriologische und experimentelle Untersuchungen iiber 
einen merkwurdigen Eall von allgemeiner gonorrhoischer Infection." Cen- 
tralblatt fur Bakteriologie, vol. xxiv., No. 25. 



7± THE IRRIGATION TREATMENT OF GONORRHOEA. 

developed an inguinal bubo, a week later an abscess of the epi- 
didymis, and eight days after that, suppuration of the parotid. 
The pus from all the abscesses, as well as the blood, was found 
to contain gonococci, from which pure cultures were obtained. 
Colombini found a boy of twenty who had never had gonor- 
rhoea and who willingly submitted to having his urethra infected 
with one of these cultures. A florid gonorrhoea resulted, which 
required many months of assiduous and patient treatment for 
its cure. 

Thurnmel, 1 of Leipsic, in commenting on this case, says that 
the culture experiments should have sufficed Colombini for cer- 
tainty that the diplococci found in the various abscesses and 
blood were true gonococci, and that humane sentiment should 
have forbidden imperilling the health and life of a young man, 
by so infecting him. Thurnmel adds that if it seems necessary 
to make any such tests, the experimenter should use his own 
urethra for the purpose — a sentiment with which all will agree. 

In a most explicit paper, which Berg 2 read before the Sec- 
tion of Practice, New York Academy of Medicine, he recites 
the details of a case whose death, twenty-nine days after the 
first symptoms of a gonorrhoea, was clearly due to systemic 
gonorrhoeal infection of the heart and kidneys without any lesion 
of the bladder or urethra. The author's deductions and literary 
researches are so instructive that justice to the reader requires 
their entire reproduction. 

"A large number of cases of ulcerative endocarditis com- 
plicating gonorrhoea have been reported. In the larger number 
of cases the heart lesion was preceded by gonorrhoeal arthritis ; 
thus Ricord and Hunter, according to See, 3 believed that gonor- 
rhoeal rheumatism was sometimes complicated by rheumatic 
endocarditis. Desnos, however, in 1877 performed the first 
autopsy upon a case of endocarditis without rheumatism, com- 
plicating gonorrhoea ; and other cases have since been reported 
in which arthritis was not present. Such a case was reported 

1 Thurnmel : Centralblatt fur die Krankheiten der Harn- und Sexualor- 
gane, July 15th, 1899. 

2 Henry V. Berg: "Pyelo-nephritis and Ulcerative Endocarditis as a 
Complication of Gonorrhoea — the Gonococcus found in Pure Culture upon the 
Diseased Heart Valve." Medical Record, April 29th, 1899. 

3 "Le Gonocoque," 1896. 



COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 75 

by Morel. 1 That inflammatory complications occur in gonor. 
rhoea has always been recognized. Many of them are due to 
direct extension of the process from the urethra or vagina into 
the deeper tissues connected with these tracts. Others are the 
result of direct inoculation of distant structures with gonorrhceal 
pus, as, for instance, gonorrhceal ophthalmia. Neither of these 
methods of infection would account for the production of a gon- 
orrhceal endocarditis. Effects upon the nervous system and 
the manifestations of general sepsis could be explained by sup- 
posing that a toxin produced by the gonococcus had been ab- 
sorbed iuto the lymphatic and circulatory system, but the find- 
ing of the gonococcus in pure culture in the vegetations on the 
valves of a case of ulcerative endocarditis complicating gonor- 
rhoea would seem to prove that the gonococcus itself has been 
carried to the site of the lesion, and has there produced the 
ulcerative manifestation. 

" For some time it was believed, when such an infection oc- 
curred, that it was the result of a mixed infection. As is well 
known, the urethra is the habitat, even in the normal state, of 
numerous varieties of germs, so that, when the mucous mem- 
brane of the urethra has been thrown into a pathological condi- 
tion through the action of the gonococcus, the pyogenic germs 
would find a ready means of entering the system and producing 
distant lesions of a septic character. Thus Weichselbaum 2 re- 
ports a complete autopsy, with bacteriological investigation of 
a case, which certainly proved that ulcerative endocarditis can 
complicate gonorrhoea as a result of mixed infection, he having 
found gonococci and streptococci upon the valves. A similar 
case was published by Ely. 3 

"His 4 and Wilms, 6 although they both published cases of 
ulcerative endocarditis complicating gonorrhoea, in which the 
cocci found on the diseased valves had morphological charac- 
teristics of the gonococcus, and behaved in the characteristic 



1 Tl$se de Paris, No. 209, 1878. 

2 Centralblatt fur Bacteriologie, 1887, 2, and "Zur Aetiologie der acuten 
Endocarditis," Ziegler's Beitrage, 1888, iv., 3. 

3 Medical Record, March 16th, 1889. 

4 Berliner klinische Wochenschrift, 1892, No. 40. 
5 Miinchner med. Wochenschrift, 1893, No. 40. 



76 THE IRRIGATION TREATMENT OF GONORRHCEA. 

manner toward Gram staining, yet considered that these cases 
were the result of mixed infection. 

" But in the last few years, particularly since 1894, many ex- 
cellent observers have reported cases in which there was found 
at the site of lesions complicating gonorrhoea only the gono- 
coccus. Thus Bordone-Uffreduzzi ? obtained the gonococcus in 
pure culture by inoculations made with the fluid from a joint 
affected by gonorrhceal arthritis. A gonorrhoea was produced 
in a human subject by inoculation with the second generation 
of pure cultures thus derived from the arthritic joint. Council- 
man 2 reports a case in which he obtained pure cultures, in a 
case of gonorrhceal septicaemia, from the joints, the pleura, the 
pericardium, and the valves of the heart. Councilman also 
quotes a case of Gluzinsky very similar to the case which my 
communication recounts, and Winterberg 3 reports a similar 
case. One of the earliest cases of this kind was that of Ley den, 4 
in which, as in my case, the gonococcus was found after death. 
Cultures from the blood during life, and from the left ventricle 
after death, remained sterile. 

"One of the most valuable cases was reported by Thayer 
and Blumer. 5 In this case, in addition to pure cultures of 
gonococcus found in the valves, the blood cultures taken dur- 
ing life showed colonies of gonococcus which would seem to 
prove that the gonococci passed by means of the blood cur- 
rent to distant portions of the body, and there gave rise to 
infections. 

" I think that at present we may believe that septic infections, 
such as occurred in my case, can be the result of the unaided 
action of the gonococcus distributed through the body by the 
blood channels." 

The first conclusive proof of the gonococcus causing peri- 
tonitis was presented by Cushing, 6 whose exhaustive investiga- 

1 Deutsche mecl. Wochenschrift, 1894, xx., p. 484. 

2 Trans, of the Association of American Physicians, 1893, viii., p. 165. 
3 Festsch. zum 25jahr. Jubil. d. Vereins Deutsch. Aerzte zu San Fran- 
cisco, 1894, p. 40. 

4 Berliner klinische Wochenschrift, January 1st, 1894, xxxii., p. 22. 

5 Arch, de Med. experimental., November 1st, 1895, vii., No. 6, p. 701. 

6 Harvey W. Cushing: "Acute Diffuse Gonococcus Peritonitis." Bulletin 
of the Johns Hopkins Hospital, May, 1899. 



COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 77 

tions add evidence to the fact that gonorhceal processes are riot 
limited to mucous surfaces. 

Besides the joints, heart, and kidney, the fourth ventricle of 
the brain has been found the seat of gonococcal invasion through 
the circulation. 

For detailed study of the gonococcus the reader is referred 
to the writings of the authors mentioned, and more particularly 
those of Henry Heimann. 1 

Gleet. — This term is used to designate any kind of per- 
sistent discharge from the urethra. As it embraces no patho- 
logical or otherwise descriptive import, it should cease to have 
a place in medical nomenclature. 

Gout. — It is well known that gout can evince itself in 
urethritis, especially of the posterior urethra, in orchitis and 
epididymitis, although these manifestations are rare. When a 
gouty patient past middle age and given to high living, con- 
tracts gonorrhoea, the possibility of the constitutional complica- 
tion should not be left out of mind. The urine, besides con- 
taining pus, is very acid and heavy with uric acid and urates. 
Suspicion is attracted to the possibility of a gouty diathesis by 
the presence of dry, scaly eczema, tophi, and ground-down teeth. 
In such cases irrigations must be followed out as in uncompli- 
cated gonorrhoea, while the patient is energetically treated by 
his family physician for the gouty condition. 

Hemorrhage. — While bleedings, from the meatus of other 
than urethral origin would be beyond the scope of this book, 
their possibility must not be left out of consideration when they 
occur with a gonorrhoea. 

The bleedings from posterior urethritis and urethrocystitis 
are discussed under their respective heads. 

Bleeding from the anterior urethra may be provoked bj r vio- 
lently employed strong injections, sharp syringes, catheteriza- 
tion through an acutely inflamed, macerated urethral mucosa, 
and the passage of small, rough calculi. 

Sometimes urethral bleeding is provoked by coitus while 
the patient has gonorrhoea, incredible as such an act may ap- 

1 Heimann : " A Clinical and Bacteriological Study of the Gonococcus Neis- 
ser," Medical Record, June 22d, 1895. "A Further Study of the Biology of the 
Gonococcus," Medical Record, December 19th, 1896. "Further Studies, Third 
Series, on the Gonococcus Neisser," Medical Record, January 15th, 1898. 



78 THE IRRIGATION TREATMENT OF GONORRHOEA. 

pear. S. Kof mann, * of Odessa, reports such a case. A healthy- 
looking individual, aged nineteen, with anxious features, told 
Kofmann that for over an hour blood had been pouring from his 
urethra in an uninterrupted stream. The patient confessed hav- 
ing gonorrhoea. Examination showed blood escaping from the 
meatus in jets as thick as a pencil, as from an artery transversely 
divided. Kofmann dipped a strip of gauze into a solution of 
alumina acetate, mounted it on a long button probe, carried it 
as deeply as possible into the urethra and packed it firmly. 
Then he applied a pressure bandage about the penis, ordered 
the patient to go to bed, to avoid urinating as long as possible, 
prescribed opium and forbade drinking. On the following day 
the patient looked better, but still considerably affected. On 
removing the pressure bandage and extracting the blood-soaked 
packing, considerable bleeding resulted. The whole dressing 
was repeated and the patient ordered to return on the following 
day. He did not do so until one and a half months later. He 
then related the history of gonorrhoea four years before, lasting 
one year. Later he had had chancroid, still later another gon- 
orrhoea and chancre, and a third clap a year before the last con- 
sultation. The discharge was very copious and the patient 
suffered much pain, especially on urinating. Despite the dis- 
ease, the patient cohabited several times. During one inter- 
course he experienced intense pain, and immediately thereafter 
found his linen blood-soaked and blood dripping from the 
meatus. Since then the bleeding had recurred frequently, 
especially after the abuse of stimulants. The bleeding then al- 
ways came on after passing clear urine, sometimes in bright red 
drops, sometimes in a stream. Compression of the penis for 
some time always arrested the bleeding ; this was followed by 
itching in the urethra, from which the patient extracted a co- 
agulum cast in the shape of the channel. Upon its withdrawal, 
bleeding immediately recurred. On the day he consulted the 
author the patient had drunk several glasses of tea and a con- 
siderable quantity of brandy. Bleeding, which then set in upon 
urination, proved uncontrollable. On the day after the second 
tamponing the patient removed the bandage and the packing. 

1 Kofmann: " Zur Tamponade der Urethra." Centralblatt der Chirurgie, 
No. 19, 1899, quoted in Monatsberichte tiber die Gesammtleistungen auf dem 
Gebiete der Krankheiten des Harn- und Sexualapparates, July, 1899. 



COMPLICATIONS AND SEQUELS OF GONORRHOEA. 79 

This was followed by a thick coagulum and several drops of 
blood. Then the bleeding stopped ; the debility resulting from 
the loss of blood obliged the patient to remain in bed for two 
weeks. The origin of this bleeding was doubtless gonorrhceal 
injury to a blood-vessel deep in the urethra, with subsequent 
laceration of the vessel. 

See also Foreign bodies and Traumatism. 

Hemospermia. — Ked or brownish semen is due to the ad- 
mixture of blood dependent upon very severe gonorrhoea or 
acute seminal vesiculitis. It is occasionally produced by mas- 
turbation, chronic orchitis, or chronic gonorrhoea. In vesicu- 
litis the spermatozoa are deformed, dead, or absent. The 
microscopic specimens also show red blood corpuscles, pigment, 
granular detritus, epithelia varying in accord with the region 
affected, and round cells. 

The most aggravated case of haemospermia that ever came 
under my notice was that of a man of twenty-eight sent to me for 
complete loss of sexual desire, erections, and even nocturnal emis- 
sions. Six months before he, for the amusement of some com- 
rades of his own intellectual calibre, had four prostitutes perform 
buccal masturbation upon him in immediate succession. At the 
fourth ejaculation he fainted, and remained unconscious for a 
long while. The physician who was called found blood oozing 
from the meatus. This continued for several hours. 

No pathological conditions were discernible when I examined 
him. Under the use of tonics, galvanism, faradization and the 
psychrophore, he undeservedly recovered his potencj^ in two 
years. 

For the treatment of haemospermia, see Vesiculitis and 
Digital Palpation of the Urethral Adnexa. 

Hydrocele. — When epididymitis, orchitis, or orcho-epididy- 
mitis complicates gonorrhoea, the extension of the inflammation 
is not rarely accompanied by acute hydrocele. The effusion is 
often so slight as to be barely perceptible and, in the majority 
of cases is resorbed, when the local inflammation subsides with- 
out any treatment being directed to it. 

When the swelling is very great and produces much painful 
tension, it is necessary, for purposes of differential diagnosis, 
to ascertain whether it is caused by serous effusion. The local 
pain, too severe to permit manipulation, is intensified when the 



80 THE IRRIGATION TREATMENT OF GONORRHOEA. 

patient is placed in the standing position to secure transillu- 
mination of the scrotal sac. 

In such cases, the simplified urethroscope described on page 
190 will fully serve, without in any manner increasing the pa- 
tient's discomfort. The light is inserted into a large urethro- 
scope tube ; its mouth is passed over the side of the scrotum 
opposite the surgeon's eyes, while the patient, whose testicles 
are elevated as described under epididymitis, is not disturbed 
at all. If the swelling is due to acute hydrocele, the light will 
pass through the scrotal layers and the fluid, but not through 
the testicle, whose body can be clearly outlined. 

If the pain does not yield to the treatment directed against 
gonorrhoeal epididymitis, relief may be promptly obtained by 
puncturing the sac with a very fine narrow-bladed knife. At 
each withdrawal of the knife, a few drops of the yellowish effu- 
sion will squirt from the tumor. According to its size, fifteen 
to fifty such punctures may be required. The pain is trifling, 
and the reduction of pain immediate. 

Consideration of hydrocele as an individual disease, result- 
ing from or preceding gonorrhoea, must be relegated to the 
large, recent works on genito-urinary diseases. 

Lymphadenitis gonorrhceica (gonorrhoeal bubo) may com- 
plicate gonorrhoea if the patient commits any kind of excesses, 
indulges in violent or too prolonged exercise, or stands for 
many hours, as book-keepers, etc., must. Then one or more of 
the superficial glands in the subcutaneous cellular tissue, above 
the fascia lata, and immediately below Poupart's ligament, may 
be affected. 

The physician who makes it a rule to examine his cases at 
each visit, is likely to discover and often abort lymphadenitis 
before the patient becomes conscious of it. The first sign of 
lymphangitis (see below) should direct attention to the groin. 
If a single or double hard swelling is found there, and even if it 
is not painful or only slightly sensitive to pressure, it should 
be treated as mentioned below. 

If the patient's attention is attracted to these glands by pain, 
it will be found that the pain is increased by pressure and by 
standing. Early in the involvement of these glands, they are 
movable under the skin. Soon, however, they become adherent 
to it and the tissues around it. The region loses its hard con- 



COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 81 

tour, becomes doughy , and assumes a reddened and later on a 
purple color. Even then, when properly treated, the inflamma- 
tion may terminate in resolution, unless the patient's resistance 
is weakened by dissipation, excessive work, malnutrition, or a 
"scrofulous constitution." Then the glands affected are likely 
to suppurate. 

At the first sign of such glandular enlargement, prolonged 
hot hip-baths, and mercurial ointment U. S. P. rubbed into the 
region twice daily may abort the case. Pressure upon the en- 
larged gland, with a well-applied spica of the groin, if the pa- 
tient must be about, may assist in resorption of the swelling. Its 
effect may be increased by neatly fitting a compressed sponge 
over the gland, and wetting it after the spica is applied. If the 
patient can remain abed, a stout bag containing three to iive 
pounds of bird-shot may be fixed upon the groin, so that its 
weight exercises continuous pressure upon the gland. 

If in forty-eight hours the above course has not brought 
about marked relief, the' enlarged gland or glands should be 
dissected out. Ordinarily this can be very well done under 
infiltration anaesthesia by Schleich's method. 

If the patient is timorous or the physician of limited surgical 
experience, the region may be anaesthetized with ethyl-chloride 
spray and the enlarged gland slit. After bleeding is arrested 
the cut must be irrigated with hot water or hot boric-acid solu- 
tion, and then filled with antinosin. This is retained by a 
covering of gauze and a spica. After two or three daily repeti- 
tions of this washing and dressing, the wound will be found 
filled with healthy granulations. Then nosophen dusted into 
it and the spica applied will ordinarily result in prompt cicatri- 
zation. 

If the case is not seen until the gland has become converted 
into an abscess, evacuation of its contents must be at once at- 
tained by free incision and curetting the cavity, which then must 
be treated as above indicated, or by packing with iodoform or 
nosophen gauze. 

Lymphangitis. — Persons who have no idea of cleanliness, or 
those with a tight meatus, or those employing dressings of the 
glans that invite retention of gonorrheal discharge, are likely 
to suffer inflammation of the lymphatics of the penis. 

At the very inception one or two superficial, diffuse, faint, 
6 



82 THE IRRIGATION TREATMENT OF GONORRHOEA. 

reddish lines show along the dorsum of the organ. They are 
rarely, if ever, observed by the patient in this stage. A day or 
two later this discoloration disappears and one or two distinct 
cords can be felt beneath the skin. These cords may start near 
the frenum, pass like a bridle upward and backward behind the 
region of the corona to the dorsum and extend to the pubis. As 
the skin over this cord or cords becomes reddened again, pain 
sets in, which increases with the thickening of the lymphatics 
involved. This pain is much aggravated during erection. With 
the increase of pain, the skin that was freely movable over the 
enlarged lymphatics sometimes becomes adherent and very sen- 
sitive even to contact of the clothing. 

In most exceptional cases, a spot anywhere along the dorsal 
lymphatics hardens, lies in the loose connective tissue, where 
it enlarges, giving but little inconvenience. The lymphatics 
behind such a knot are then not enlarged. The knot itself 
eventually breaks down into an ordinary abscess. 

When a case of gonorrhoea presents, showing the preliminary 
light red lines, they subside after one or two . irrigations, with 
all the precautions for cleanliness described under the technique 
of irrigation. 

If thickening of the lymphatics has set in, in addition to 
irrigations, the penis is kept enveloped in cloths wet with equal 
parts of alcohol and lead water, renewed whenever they begin 
to get warm. Severe cases may require the patient to keep 
abed, to rise only for hot sitz-baths, or entire hot baths three 
or four times daily. If erections are frequent and painful, 
either monobromate of camphor or bromide of potassium gen- 
erally controls them. These drugs failing, morphine may be 
used. Throughout, attention must be given to free intestinal 
evacuation. 

If the case has progressed to suppuration, the abscess must 
be promptly opened, curetted, and packed with iodoform or 
nosophen gauze. 

Neuroses (gonorrhoea!) . — While most diseases carry with 
them more or less marked nervous depression, there is none in 
which it is more evident or more frequent than gonorrhoea. The 
cause of nervous manifestations even at the inception of clap 
may be attributable to the consciousness of being physically 
unclean, or of being a menace to others; or they may be at- 



COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 83 

tributable to the deprivation from habitual sexual intercourse 
or stimulants. More recent investigations, however, make it 
appear that the gonococcus toxins directly attack the nervous 
system. At all events Leleneff 1 reports the following disturb- 
ances of the nervous system produced by gonorrhoea : 

(1) Changes in the sensory nerves, causing anesthesia, 
hyperesthesia, paresthesia, and pain in the nerves, in the skin, 
in joints, in muscles, and in internal organs; (2) changes in 
the vasomotor nerves, causing hyperemia, anemia, paralysis of 
vessels, and dermographism; (3) changes in the secretory 
nerves, causing increased or diminished sweating, local sweat- 
ing, an increase in the flow of mucus from the urethra, etc. ; (4) 
changes in the trophic nerves, causing some forms of skin dis- 
ease, atrophy of the testicle, and muscular atrophy; (5) changes 
in the motor nerves, causing paresis, paralyses, and twitchings ; 
(6) changes in the skin reflexes and tendon reflexes. Gonor- 
rhceal affections of the central nervous system give rise to a 
variety of symptoms, such as asthenic neuropsychosis, neuras- 
thenia, hemiplegic phenomena, etc. 

These disturbances, however, seem to premise that gonor- 
rhoea, to produce them, must be implanted upon an existing 
neurotic tendency. Beard 2 has shown that Americans are more 
prone to this complication than are patients of other nationali- 
ties. He attributes this to our unfavorable climate, overwork, 
anxiety, excesses in tobacco and alcohol. 

This view is confirmed by my observations in European 
genito-urinary dispensaries and hospitals, where neurasthenia 
complicating gonorrhoea is certainly far less frequent than it is 
among us. 

Von Krafft-Ebing 3 reports only eight cases in which local 
genito-urinary disease was manifest in one hundred and four- 
teen cases of neurasthenia. 

Lowenf eld 4 is of the opinion that most of those afflicted with 



leleneff: "The Nervous System in Gonorrhoea." Wratch, No. 4, 1899, 
excerpted by Medical Record, July 15th, 1899. 

2 Beard: "Sexual Neurasthenia." 

3 Von Krafft-Ebing : "Ueber Neurasthenia Sexualis beim Manne." Wie- 
ner medicinische Presse, No. 5 et seg., 1887. 

4 Lowenfeld: "Sexualleben und Nervenleiden," Bergmann, Wiesbaden, 
1899. 



84: THE IRRIGATION TREATMENT OP GONORRHOEA. 

clap-neurasthenia are individuals with hypochondriacal predis- 
position, in whom the consciousness of suffering from a genital 
affection evokes persistent mental depression and frequently 
most exaggerated worry regarding its possible consequences. 
Such a patient continually directs his thoughts to the condition 
of his urethra, watches its secretions with anxious care, and sub- 
mits to interminable attempts at curing it with astringents and 
cauterizants. This author concludes that clap-neurasthenia is 
more frequently the result of chronic maltreatment of the ure- 
thra than of its disease. 

Every practitioner, and particularly every specialist, has seen 
innumerable cases in which urethritis has been maintained in- 
definitely by over-treatment, even when the methods employed 
correctly met the indications while the disease existed. 

Naturally then, when discharge and floaters in the urine are 
made to continue by urethral maltreatment, or continuance of 
treatment when it has become unnecessary, the neuroses pro- 
voked by the manifestations of apparent disease must continue. 
The more persistent these neuroses are, the more difficult their 
cure becomes. 

When all discharge has ceased, the presence of floaters in 
the urine, which may continue for several weeks after a gonor- 
rhoea has subsided, may disturb the patient's mind. Some 
patients, even when the urine is perfectly clear, acquire remark- 
able dexterity in stripping the urethra, by which they can at 
almost any time produce a minute drop of normal secretion at 
the meatus, to which they point as evidence of their uncured 
condition. 

When in such cases the urethroscope shows the absence of 
disease, it is the physician's duty to direct his treatment to the 
mental condition, lest the patient be driven by its persistence 
to the quacks, who will gratify the patient's desire for active 
local maltreatment as long as he can pay for it. Arguments 
and evidence of the microscope are only exceptionally of avail. 
The more palpable the physician's honesty is, the less he will 
be able, as a rule, to convince such a patient that the healthy 
urethra must be left alone. 

Under such circumstances, it is perfectly justifiable to per- 
suade such a patient that the passed gonorrhoea has affected his 
constitution and that he requires constitutional treatment for 



COMPLICATIONS AND SEQUELS OF GONORRHOEA. 85 

its cure. Ordinarily the drugs administered must, to be effec- 
tive, have a decided taste, such as tincture of nux vomica in 
watery solution. It will be well to warn such patients against 
the disastrous effects of "squeezing out the perennial drop" 
while taking this drug or any other that may be used. (See 
also Chronic Gonorrhoea.) 

If the neurasthenia persists despite all suggestive treatment 
that the physician's ingenuity may devise to suit the special 
manifestations in each case, or the peculiar bent the mind has 
taken, the patient should be referred to a neurologist, because 
then it has gone beyond the field of general practice or the 
genito-urinary specialty. 

It must, however, never be forgotten that a very minute ure- 
thral lesion can maintain a neurotic condition, even when not 
the slightest discharge can be brought to the meatus and the 
urine remains perfectly clear. If such a lesion exists, it can be 
found. When it is properly treated, the neurasthenia subsides 
with or shortly after its disappearance. 

"When gonorrhoea has destroyed tissues or organs through 
changes in the trophic nerves, surgical intervention may be re- 
quired, to restore the patient's nervous and mental equilibrium. 
Several cases are reported in which an atrophied testicle was 
substituted by a celluloid body, with satisfactory results, as far 
as the patient's mental state was concerned. 

(Edema of the skin of the penis may complicate gonorrhoea, 
especially in persons who. keep the organ in a filthy condition. 
It subsides with attention to cleanliness. 

In a number of cases, an immense oedema of all the tissues 
of the penis sets in almost immediately after the first or second 
irrigation. This is painless and disturbs the patient in no wise, 
except by the sensation of a large bulk in the trousers. In the 
majority of cases, when this oedema occurs, the gonorrhoea will 
be aborted in a very short time, probably because then no parts 
of the organ remain a favorable culture medium for gonococci. 

Ophthalmia, gonorrhoea!. — Whenever a patient with gonor- 
rhoea, or one who has come in contact with the disease, shows a 
slight reddening of the conjunctiva, with an increased flow of 
tears, the latter should be examined microscopically. Whether 
gonococci are found or not, the patient should without a mo- 
ment's loss of time be referred to an ophthalmologist. 



86 



THE IRRIGATION TREATMENT OF GONORRHOEA. 



If a specialist in eye diseases is not instantly accessible, the 
patient should be put to bed and, until the ophthalmologist 
arrives, small compresses taken from a block of ice must be put 
upon the eye, every two or three minutes, day and night. 

Silver nitrate, as laid down in works on ophthalmology, 
should be employed as soon as the secretion becomes creamy. 
The healthy eye should be protected by an occlusive dressing. 
Buller's dressing has the advantage of permitting continual in- 
spection and conse- 
quent early treat- 
ment, if the healthy 
eye has become in- 
fected. 

OECHI - EPIDIDYMI- 
TIS — see Epididy- 
mitis. 

Paraphimosis 
complicating gonor- 
rhoea does not fre- 
quently assume a 
severe form, and it 
usually subsides as 
the gonorrhsea im- 
pr o ves . When, 
however, a patient 
attempts forcibly to 
reduce a gonorrhceal 
phimosis and man- 
ages to slip the fore- 
skin beyond the glans, the preputial orifice soon becomes rigid, 
constricts the penis, which then swells, producing the familiar 
deformity. If the constriction and consequent oedema are not 
promptly relieved, the penis presents three distinct swellings 
and three more or less deep contractures, as shown on the ac- 
companying drawing. 

1. The margin of the corona is much swollen, forming a 
thick ridge. 

2. The coronary sulcus rendered deeper by the swelling 
around it. 

3. Glistening mucous fold sometimes overlapping the sulcus 




Fig. 18.— Paraphimosis. 



COMPLICATIONS AND SEQUELS OF GONORRHOEA. 87 

and glans, formed of that part of the preputial mucosa that lay 
upon the posterior aspect of the corona. 

4. A very deep, tight, constricting band; this is the pre- 
putial cutaneo-mucous margin, and, beinj the real point of con- 
striction, is the cause of the trouble in this position. It is the 
surgical point of paraphimosis, the one that must be severed 
when operation becomes necessary. 

5. Behind the hard constriction is another thick roll, con- 
sisting of preputial integument crowded back and held there by 
the constriction. 

6. Another furrow, less deep and less tight than the former, 
is formed by the swollen tissues crowding back upon those that 
are not involved in the constriction before them. 

This general type of paraphimosis may suffer a number of 
variations : the rolls of mucosa and skin may become so thick 
as to cover the furrows beneath them ; the penis may be so con- 
stricted at the second furrow as to make it look as if bent for- 
ward at a right angle upon itself; the constriction may be lateral, 
giving the penis a twisted appearance. 

When dislocation backward of the prepuce is recent, it may 
often be reduced by manipulation, after soaking the penis in a 
hot antiseptic solution for twenty or thirty minutes. Then, 
after drying the organ, a little vaseline or lubrichondrin is ap- 
plied within the second constricting furrow, but nowhere else, 
lest it render the organ too slippery for manipulation. The 
penis is then grasped and steadied by the index and middle 
fingers of both hands,* passed from both sides so that the tips 
of the indices touch each other on the dorsum, while the middle 
fingers cross below. In this position the fingers compress the 
third roll, while the thumbs perform a species of massage upon 
the glans as they strive to crowd it back within the prepuce. 
If it will yield at all, it will do so in a few minutes of this 
manipulation. 

If the paraphimosis cannot be reduced by manipulation, or 
if efforts to perform it are excessively painful, or if the constric- 
tion has become too dense to yield, it will be promptly relieved 
by incision in most cases. 

Neglected cases usually end by necrosis at the central dorsal 
point of the second furrow. Following this indication, the 
surgeon passes a sharp-pointed, curved, narrow bistoury be- 



88 THE IRRIGATION TREATMENT OF GONORRHOEA. 

neath the constriction, gathering it upon its edge as if it were 
a cord. In doing so, he takes care not to wound the corpora 
cavernosa. In severing the " cord " it may impart quite a carti- 
laginous sensation to the knife. If the first cut is not successful 
in relieving the tension, a second may be made. 

In case the swelling so overlaps or distorts the furrows that 
the second one cannot be found, a straight, narrow knife is used 
instead of a curved one. The penis is then rested in the palm 
of the left hand while the thumb and fingers depress and render 
tense the folds. Then the skin and mucous membrane are 
incised firmly, holding the knife perpendicularly to the axis of 
the penis, but not cutting more deeply than the integumentary 
coverings. These incisions must be continued until the con- 
striction is felt to give way. In such case the incisions along 
the dorsum of the penis should be no longer than the length of 
the glans. 

When the constriction has been severed, the foreskin can as 
a rule be easily drawn forward. It will then appear as if it had 
been slit. Ordinarily the cut heals soon, leaving a dog's-ear 
foreskin, which subsequently may be remedied by complete cir- 
cumcision. 

Periarthritis — see Rheumatism. 

Phimosis. — While many fine distinctions are made by au- 
thors regarding irretractibility of the foreskin, Taylor's 1 defini- 
tion embraces all practical requirements: "Phimosis is that 
condition of the prepuce which prevents its retraction and the 
exposure of the glans. It may be congenital or acquired." 

Many boys are born with a redundant prepuce. With some 
it is so tight that it cannot be withdrawn. It is debatable 
whether any boys are born with adhesions of the prepuce to the 
glans ; at all events, in most of those whom I have circumcised, 
the prepuce had at least a few adherences. In some the adher- 
ence was so general as to oblige complete dissection of the 
inner lining from the glans. 

The growth of the prepuce sometimes does not keep pace 
with that of the rest of the organ. The result may be an arrest 
of development of the glans. In one case treated in my class 
in the New York School of Clinical Medicine, the patient, a 

Baylor: Venereal Diseases, Lea Brothers & Co., Philadelphia, 1895. 



COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 89 

negro, aged thirty-eight, had a fully developed penis, except as 
to the glans, which was no larger than that of a small boy of 
twelve years. After liberation of the glans by circumcision of 
a very small, tight, thick, unyielding foreskin, the glans began 
to develop and in three months' time attained almost its normal 
dimensions. 

A tight foreskin, even when not redundant, by its irritation 
is likely to provoke masturbation. Normal secretions, or drops 
of urine retained and decomposed within the preputial sac, may 
cause ulcerations and heavy strong adhesions whenever these 
ulcerations heal. Concretions of smegma, sometimes quite hard 
and friable, are often found lying about the glans, and especially 
in the coronary sulcus. Urinary salts are sometimes deposited 
in this region. All these substances act as foreign bodies erod- 
ing the delicate mucosa; by accretion they may become adherent, 
embedded, and often produce extensive ulcerations. 

Local symptoms of phimosis may be entirely absent, the 
mucosa accustoming itself to the irritation even of inspissated 
pieces of smegma or urinary concretions. They then will be 
discovered only accidentally or when an infection obliges the 
patient to seek professional advice. Ordinarily, however, there 
is at least heat about the glans. More frequently all the local 
evidences of balanitis or balanoposthitis with their conse- 
quences — new adhesions, venereal warts and fissures — call for 
treatment. 

Phimosis may lead to obstructive conditions due to the ad- 
hesions, retained secretions, or subpreputial calculi mentioned 
above, or the preputial orifice may be so tight as to prove an 
obstruction to the free emission of urine. Then vesical irrita- 
bility, dilatation of the bladder, ureters, and renal pelvis may 
obtain. Hemorrhoids and hernia may also result from the 
heavy pressure required in attempts to force the urine through 
the obstacles. 

The liberal supply of nerves to the glans, when pressed 
upon by a tight foreskin and its local results, often reflexly 
evokes diseases such as convulsions in children, urinary re- 
tention and incontinence, unduly frequent erections, excessive 
seminal emissions, spastic paralyses, pseudo-hip-joint disease, 
muscular incoordination, etc. Naturally their presence with or 
developing in a phimosed patient does not make the tight fore- 



90 



THE IRRIGATION TREATMENT OF GONORRHOEA. 



skin the only etiological factor; still, its possibility must not 
be overlooked. 

When phimosis develops from neglected gonorrhoea, it ordi- 
narily subsides shortly after beginning irrigations, unless heavy 




Fig. 19.— Applying Constrictor. 



lymph deposits have organized in the preputial tissues. In 
such cases, or when phimosis precedes gonorrhoea, circumcision 
should be performed as soon as the more acute symptoms have 
subsided. But when the preputial orifice is so small as to pre- 
vent exposure of the meatus, or when adhesions are so numerous 
and tight that the glans cannot be cleansed, circumcision will 
be required despite the acute gonorrhoea. 

The objections that may be offered to circumcision during 
acute gonorrhoea are : 

1. Possible infection of the wound, especially when the ure- 
thritis is of a mixed character. 

2. Difficulty of manipulation of the penis, as in irrigations, 
before the circumcision wound has healed. 

To prevent infection of the cut, as far as possible while the 
patient has acute clap, a continuous stream of mercuric bichlo- 



COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 



91 



ride 1:30,000 should bo kept running over the entire field of 
operation, from its beginning to its end. 

The other objection is easily overcome by the circumcision 
I invariably practise, which may be concisely described in the 
following directions : 

1. Thoroughly scrub the penis, and especially as much of 
the mucous fold of the prepuce as can be reached, with soap 
and hot water. 

2. Irrigate the preputial sac with hot potassic permanganate 
solution 1 : 6,000 until the fluid that flows from it is entirely 
clear. 

3. Envelop the anterior four-fifths of the penis in absorbent 
cotton soaked in mercuric bichloride 1:2,000. 

4. Tie a rubber band as tightly as it can be drawn around the 
root of the penis (Fig. 19). As brutal as this precaution against 




Fig. 30.— Freezing Tip of Foreskin. 



hemorrhage may appear, it is quite painless, and its only result 
is some ecchymosis of the penis, which subsides in a few days. 
5. Pass a probe as large as the preputial orifice will admit 
into the sac and sweep it around all its parts to ascertain if the 
prepuce is anywhere adherent. 



92 



THE IRRIGATION TREATMENT OF GONORRHOEA. 



6. Freeze a small spot at tlie tip of the foreskin with ethyl 
chloride (Fig. 20). 

7. Inject into the frozen spot a drop of Schleich's 1 solution 
No. 1 (Fig. 21). 

8. At the posterior margin of the bleb so produced inject 
another drop within the skin. Continue the line of drops along 




FiG. 21.— Injecting First Drop of Anaesthetic Solution. 



the dorsal aspect of the prepuce to a quarter of an inch beyond 
the point where the elevated margin of the corona is felt through 
the foreskin. 

9. Inject a similar line of drops following the line of the 
coronary margin until the region of the frenum is reached on 
one side. Repeat this procedure on the other side. 

10. Keep the syringe loaded for more infiltration, especially 
when the preputial orifice is so tight that the mucosa cannot 
be exposed. 

11. Pinch up the dorsal aspect of the prepuce with the left 
thumb and index finger. 

12. Insert the blunt arm of a pair of probe-pointed scissors 
and carry it back as far as possible toward the corona. Drop the 
prepuce upon the blade of the scissors ; inexperienced operators 

, Schleich: Schmerzlose Operationen, Springer, Berlin, 1894. 



COMPLICATIONS AND SEQUELS OF GONORRHOEA. 



93 



will do well to sweep the scissors about under the foreskin, 
while the left fingers feel it, especially in infants, to be sure that 
the scissors arm is not within the urethra (Fig. 22). 

13. Draw back the skin and thus render it as tense as possi- 
ble. Cut through the part of the foreskin that lies between the 
scissors blades. This will produce a large cut through the skin 
and a disproportionately small cut into the mucosa (Fig. 23). 

14. Grasp the cut angles of the skin and mucosa with artery 
clamps, hold one in the left hand and give the other to an as- 
sistant. "While the mucosa is thus tensely held, infiltrate drops 
of the Schleich solution along the mucosa as far as possible in 
a line toward the corona. Cut the mucosa as far as this line 
goes. Repeat the linear infiltration in the part that is now ex- 




FiG. S3.— Inserting Scissors. 



posed. Continue cutting and infiltrating to within three-eighths 
of an inch of the corona. 

15. Repeat the entire procedure along the lateral lines reach- 
ing from the dorsum of the prepuce to the frenum, on both 
sides, leaving a collar of mucosa three-eighths of an inch wide. 
Let the prepuce then hang from the region of the frenum, to 
serve as a convenient handle for further manipulations (Fig. 24). 



94 



THE IRRIGATION TREATMENT OF GONORRHOEA. 



No bleeding, beyond a slight oozing, will interfere with the 
above steps, if the rubber band about the root of the penis has 
been firmly applied. Should bleeding to a disturbing extent set 
in, another and tighter band around the root of the penis will 
remedy the defect, or the bleeding vessels may be ligated. 

16. Pass a needle armed with six inches of or 00 catgut 
through the mucosa, at the centre of the dorsum of the penis. 
A straight Gentile's (Fig. 26) modification of the Hagedorn 
needle will be found admirable for quick work. The needle 




Fig. 23.— First Dorsal Incision. 



should transfix the mucosa at one-eighth inch from its cut margin. 
Take up the skin in the same manner and tie the skin and mu- 
cosa into neat, tight, but not wrinkled apposition, with a double 
surgical knot. Take care that the cut edges of skin and mucosa 
embrace no cellular tissue. Grasp the free ends of the catgut 
in the jaws of an artery forceps and lay it on the abdomen which 
has been covered with a sterilized towel. This will serve to 
readily distinguish it from the other sutures at the close of the 
operation. 

17. Apply similar sutures, each six inches long, to bring skin 
and mucous membrane together around the entire cut edges, 



COMPLICATIONS AND SEQUELS OF GONORRHOEA. 95 




Fig. 24.— Lateral Incision. 



until within one-fourth inch of each side of the frenum. Always 
take care that no connective tissue is allowed to project between 
the lips of the wound, which would then not have the advantage 




Fig. 35.— Inserting the First (Dorsal) Suture. 



THE IRRIGATION TREATMENT OF GONORRHOEA. 



of primary union. Wherever a bit of this tissue cannot be 

forced back to remain, another suturing of skin to mucosa over 

it will accomplish the desired end. After knotting each suture 

at the wound lips, tie its free ends together in a 

slip knot so that each pair of sutures can be easily 

found together at the conclusion of the operation. 

18. Raise the prepuce where it hangs from 
the frenum and replace the skin and mucosa in 
their original relative positions. While an assist- 
ant so stretches the foreskin, pierce its base along 
the frenum with a needle armed with six inches of 
catgut twice the thickness of that used before. 

19. Give the ends of the suture to the assistant 
who stretches it at a tangent to the axis of the 
penis. Take the prepuce in the left fingers, rais- 
ing the penis. Then, avoiding the suture held 
by the assistant, cut off the foreskin neatly along 
the line of the frenum. Tie the ligature to bring 
the skin in coaptation with the exposed part of 
the cut frenum. Grasp the ends of the suture 
with an artery clamp, and place it upon the scro- 
tum, which has been covered with a sterilized towel. 

20. Examine the entire line of sutures, to be 
sure that neat coaptation is everywhere obtained. 
Wherever connective tissue projects between the 
lips it must be returned, and if it will not remain 
beneath the lips, an additional suture placed over it. 

21. Slowly relax the rubber band that con- 
stricts the root of the penis. In a few moments 
there may be some oozing from the lips of the 
wound. If more than mere oozing results, addi- 
tional sutures will control the bleeding. 

22. Fold a strip of ten-per-cent. iodoform gauze 
or three-per-cent. nosophen gauze, eight inches long 
by one and one-half inches wide, into four smooth, 
equal, longitudinal folds. Have it stretched by 

the assistant (Fig. 30) at right angles over the first suture, 

whose ends are held by the artery clamp lying on the abdomen. 

23. Eelease the suture from its clamp, separate its ends, and 

pass them around the gauze. Tie the gauze firmly against the 



COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 97 




Fig. 27.— Disposal of First Suture. 




FIG. 28.— Lateral Sutures Applied. 



98 



THE IRRIGATION TREATMENT OF GONORRHOEA. 



first knot, by which the skin and mucosa were brought together. 
Repeat this procedure with each suture, whose corresponding 
ends, though now all are matted together with blood, can be 
easily found, because they were tied together with a slip-knot. 
The gauze must everywhere be laid smoothly upon the wound 
lips ; its tension must be even. 

24. When both ends of the gauze are hanging from the last 
suture at either side of the frenum, release the suture from the 




Fig. 29.— Cutting Off Prepuce. 

Note : Two gentlemen assisted at the operation above depicted. When performed with one 
assistant the upper end of the frenal suture can be held by the ring and little fingers of the hand 
that holds tbe clamp. 

clamp lying on the scrotum and give its ends to the assistant, 
who stretches them apart while placing the penis on the pubis. 

25. Take the gauze strip pendent from the left side and lay 
it smoothly to the right side of the penis, upon the knot of the 
suture being stretched by the assistant. Then place the end of 
gauze pendent from the right side and cross it to the left (Fig. 
31) . Firmly tie the two ends of gauze within the last suture. 

26. Cut off the projecting ends of gauze and trim the catgut 
sutures beyond their knots, leaving a smooth neat collar of 
gauze, about a quarter of an inch behind the corona, firm enough 
to press any ununited parts of the wound into coaptation, but 



COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 99 




Fig. 30.— Applying Gauze Collar. 

not tight enough to exert the slightest pressure upon the penis 
or give pain during erection (Fig. 32). 

A little blood will ooze into the collar. This will swell 



J 




Fig. 31.— Closing Gauze Collar. 



100 



THE IRRIGATION TREATMENT OF GONORRHOEA. 



slightly, and in so doing press any little gapings of the wound 
lips together. 

A light gauze bandage will steady the ring in walking. It 
should be so applied as to leave the whole glans free, that none 
of the dressing be soiled by urination. As the glans, so ex- 
posed, would suffer from friction with the clothing, it must be 
covered thickly with vaseline, over which a wad of absorbent cot- 
ton is placed and tied around the penis with a strip of gauze. 




Fig. 32.— Circumcision Completed. 



After each urination, fresh vaseline and cotton are applied by 
the patient. In two or three days the mucosa over the glans 
will be sufficiently hardened to render this protection unneces- 
sary. 

If the patient requires treatment for gonorrhoea, irrigations 
can be performed, and by using a little additional care in hand- 
ling the penis, without pain from the operation. 

Ordinarily, i.e. when the patient requires no treatment for 
gonorrhoea that moistens this dressing, the gauze ring will in a 
day become as hard as stiff pasteboard. In from four to eight 
days the catgut holding the wound lips together will be ab- 
sorbed; the ring will then drop off, leaving the line of primary 



COMPLICATIONS AND SEQUELS OF GONORRHOEA. 101 

union in evidence of the care and neatness witH which the 
operation has been performed. 

In circumcising children or unruly boys, general anesthesia 
proves preferable to infiltration. "When the latter is properly 
employed, it renders the entire operation absolutely painless. 

When phimosis accompanies gonorrhoea, associated with 
chancre or chancroid, the danger of sloughing of the wound 
prohibits circumcision. As, however, the clap must be treated 
and as the sores may produce large destruction of tissue, unless 
they receive attention, it becomes necessary to expose the glans 
entirely. This is best accomplished by two lateral incisions, 
one on each side of the penis, half-way between the frenum and 
the dorsal median line of the foreskin. In most cases, Taylor's 
phimosis scissors will be found useful; still as often very hard 
preputial infiltrations may render its employment difficult, a 
stout, slightly curved sharp-point bistoury will be found more 
effective. It is passed upon a grooved director w r hich has been 
inserted into the coronary sulcus, the preputial skin drawn back 
as far as possible, the knife made to penetrate the mucosa, the 
intervening tissue and to project from the skin, cuts a steady, 
straight line outward. This cut is repeated on the opposite side. 

The operation should be preceded by very thorough anti- 
septic irrigation of the preputial sac. After both sides of the 
prepuce are slit, a large flap of foreskin projecting above and 
another hanging below will expose the entire glans for examina- 
tion and treatment as soon as bleeding has ceased. 

Pollutions. — There is no symptom in connection with gon- 
orrhoea that does less harm and creates more consternation than 
an emission of semen, especially in a patient whose mind has 
been misdirected by quack advertisements. It is often difficult 
to persuade such a patient into appreciation of the essential 
facts, viz. : 

1. That in abstinence from sexual intercourse occasional 
emissions of semen from the overfilled seminal vesicles are per- 
fectly normal. 

2. That the local irritation of gonorrhoea is likely to evoke 
emissions more frequently than they would occur in health. 

3. That no proximate or remote injury will come to the pa- 
tient from such emissions, when they are not too frequent. Their 
frequency may vary widely within normal limits. 



102 THE IRRIGATION TREATMENT OF GONORRHOEA. 

4. That only when the semen emitted is bloody, or when its 
emission gives pain enough to awake the patient, is it indica- 
tive of seminal vesiculitis and then requires attention. 

If the patient's intellect is too limited to permit him to grasp 
these ideas, the physician is perfectly justified in employing 
such subterfuges as will best appeal to the patient's understand- 
ing. The one that succeeds most frequently is to felicitate the 
patient on the occurrence of these pollutions and to offer him 
remedies that will cause their continuance. The "remedies" 
then prescribed must naturally be only placebos. 

At the same time, a towel tied around the waist and heavily 
knotted over the spine to prevent the patient sleeping on his 
back, and light evening meals, will contribute to reducing the 
frequency of pollutions. 

Prostatitis. — Wossidlo 1 insists that no case of gonorrhoea 
be dismissed as cured before the physician has assured himself 
that the prostate is free from invasion. If this advice were al- 
ways followed, there would be few, if any, cases of recurrent 
gonorrhoea. 

The almost direct manner in which the prostatic ducts empty 
into the posterior urethra seems to invite infection from this 
region to the prostate, by continuity of surface. Bransford 
Lewis 2 supports his own studies of the frequency of infection of 
the posterior urethra, by the statistics of other authors, such as 
Letzel, who found posterior urethritis in 92.5 per cent, of gon- 
orrhoeas, Jadassohn in 87.7 per cent., Eona in 79.7 per cent. 
My own observations have led to the views expressed in the 
chapter on Acute Posterior Gonorrhoea. 

Like posterior urethritis, gonorrhoeal prostatitis may give 
but slight or practically no manifestations of its presence. It 
is therefore likely to be overlooked unless one makes it a rule 
to follow Wossidlo's sage advice. 

A slight discomfort about the perineum and rectum may be 
the only indication of the disease. If this does not receive at- 
tention, pain referred more directly to the bladder may follow. 

1 Wossidlo: "Treatment of Chronic Prostatitis." Journal of the Ameri- 
can Medical Association, August 27th, 1898. 

2 Lewis: "The R61e of the Posterior Urethra in Chronic Urethritis." 
Read before the American Association of Genito-Urinary Surgeons, June 21st, 
1893 (reprint from Medical Record). 



COMPLICATIONS AND SEQUELAE OF GONORRHCEA. 103 

The pain is accentuated by urination and defecation, especially 
when efforts are necessary to expel hard faeces. The patient is 
obliged to urinate frequently, but does not experience complete 
relief from the act. While the frequency may, in great degree, 
be caused by the coincident posterior urethritis, there is neces- 
sarily an amount of urine retained in the bladder. The quantity 
of residual urine is in proportion to the degree of prostatic 
engorgement. This pushes that part of the bladder which lies 
over the prostate upward into the vesical cavity. Behind this 
elevation a trough is produced, from which the bladder con- 
tractions do not suffice to force all the urine it contains above 
the hillock made by the enlargement. Sometimes the entire 
lower part of the enlarged prostate juts into the bladder cavity 
in such a manner as to form a species of valve. This is shown 
after such a patient has voided all the urine he can extrude by 
irrigating his bladder with a potassium permanganate solution. 
No difficulty opposes the inflowing solution, because it forces 
the prostate back toward its place. But when the patient voids 
all he can of the solution, it will be found decolorized by the 
retained urine if it is normal, or rendered brown, "muddy," in 
case the urine has become septic. 

The prostate in this condition may cause "stammering" 
urination, as Guyon graphically describes it. The patient, by a 
series of contortions, invites the stream which, while he holds 
himself in a certain position, may flow freely; then suddenly 
an untoward motion throws the enlarged prostate against the 
internal meatus and urination stops. The greater the efforts 
made, the more firmly is the bladder outlet blocked. Only after 
successful efforts at relaxation does the prostate fall back and 
allow the urine to flow. But the bladder contractions may force 
the prostate up, and let it drop again, producing the character- 
istic stammering. The end of urination may be painful and 
accompanied by emission of pus and blood. When the conclu- 
sion of urination is so disturbed, neither the pain nor extrusion 
of pus and blood is as marked as in acute posterior urethritis. 
Naturally, if the prostatic trouble accompanies posterior ure- 
thritis in the fulminant form, the severe symptoms of the latter 
will overshadow those produced by the engorged prostate. 

The frequency with which acute prostatitis complicates pos- 
terior urethritis is disputed. This may be due to the omission 



104 THE IRRIGATION TREATMENT OF GONORRHOEA. 

of prostatic examination and to subsidence of its severer symp- 
toms with the decrease of those of the urethritis. 

On examining the prostate per rectum, the ringer finds the 
gut hot, more or less firm and tender to the touch, according to 
the degree of inflammation. The anterior wall itself bulges 
downward and backward into the rectal space. The enlarged 
prostate, very tender to the touch, can be outlined through the 
rectal wall. These findings are the only ones by which prosta- 
titis can be differentiated from posterior urethritis. 

The rational division of this complication into simple acute 
prostatitis, acute follicular and parenchymatous prostatitis is 
sufficiently explanatory of the varieties. Their detailed con- 




Fig. 33.— White and Martin's Rectal Injector. 

sideration is unnecessary in a book limited to treatment, which 
does not materially differ in the several forms of the disease. 

If the case is seen at the inception of the prostatic involve- 
ment, the patient must be put to bed, with a sewing-board or 
leaf of an extension table under that part of the mattress upon 
which his buttocks rest. Upon this a thick hair pillow is placed 
to elevate the pelvis. The intestinal discharges are kept soft 
by skimmed milk to the exclusion of other food, and the urine 
bland by alkaline diuretics. Irrigations of the urethra and 
bladder are as a rule exceedingly well borne during acute prosta- 
titis, especially when the manifestations of posterior urethritis 
are marked. 

If perineal pain and vesical tenesmus are severe, leeches to 
the perineum will furnish relief. 

Eectal irrigations, hot or cold, according to the local and 
general condition, often give very prompt relief. The most con- 
venient instrument for these irrigations is the rectal injector 



COMPLICATIONS AND SEQUELJE OF GONORRHOEA. 105 

described by White and Martin, who direct its use as follows : 
"A quart of a seven-tenths-per-cent. salt solution is heated from 
110° to 115° P., and the injection pipe is introduced into the 
anus and its end tilted upward and forward so that the stream 
when it is turned on shall flow directly on the prostatic tumor 
as it bulges into the rectum. The exit pipe allows the fluid to 
flow away as fast as it enters the bowel. This treatment should 
be repeated two or three times a day." 

When using this rectal irrigator, I found that larger quanti- 
ties of hot water, two or even three quarts, gave more relief than 
one. After each rectal irrigation a suppository of 

Iodoform, pulv., gr. ss.-iss. 

Codein. phosph., gr. |-i. 

01. theobrom., q. s. 

will aid in resolution, and further assuage pain. 

Some patients bear cold irrigations much better than hot 
ones. In the beginning of prostatic involvement they occasion- 
ally act better ; indeed, if used early enough, they often appear 
to abort the case. 

Hot baths, and particularly hot sitz-baths, twice or three 
times daily, of ten to twenty minutes' duration each, will often 
give marked relief. In some cases a hot-water bag to the peri- 
neum aids in making the patient's condition tolerable. 

Persistent severe pain and tenesmus, both vesical and rectal, 
may oblige recourse to opium administered by the rectum or 
morphine injected deeply into the perineum. 

When prostatic enlargement prevents urination and the oth- 
er means suggested for relief fail, or when the emergency of 
the case demands, recourse must be had to catheterization. As 
repetition of the use of the catheter will be required, and is 
painful, it will be well, when the urine is retained because of 
prostatitis, to employ permanent catheterization (see Eetention). 

If the prostate has become the site of pus formation, no 
time should be lost by any of the above procedures. Palpation 
through the rectum will reveal whether fluctuation points toward 
the bowel. If it does not, fairly moderate pressure may cause 
the pus to escape into the urethra; indeed, it is often so re- 
lieved by nature. In case this effort fail, it may bo supple- 
mented by the introduction of a Benique or Guyon sound, which 



106 



THE IRRIGATION TREATMENT OF GONORRHOEA. 




\ 



offers increased resistance, and performing massage while the 
sound is held in the bladder. But unless the physician has 
large experience in the use of genito-urinary instruments and is 

endowed with great delicacy of touch 
he should certainly avoid the use of 
these sounds, es- 
pecially in acute 
inflammatory con- 
ditions. 

I f fluctuation 
does not distinctly 
point rectumward, 
and if nature or 
massage does not 
empty the pus into 
the urethra, a me- 
dian perineal 
incision will be re- 
quired for its evac- 
uation and sub- 
sequent thorough 
drainage. 

When, how- 
ever, pus distinctly 
points to the rec- 
tum, it may be 
111 considered as na- 
ture's indication of 
the most favorable 
site for evacuation. 
M^ Acting upon this 

j/^fr suggestion, I have, 

^^jjjpr in eight cases, 

^jJ||P^ opened prostatic 

%J^^ abscess by a long 

incision through 
the anterior rectal wall, packed the cavity with iodoform gauze, 
and have not observed one case of general infection. It is true 
that in each of these cases the rectum was on the point of break- 
ing down when I operated. 



COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 10? 

In the above, termination of prostatitis by resolution or sup- 
puration only has been considered. Prostatitis may also go 
over into a chronic inflammation of the gland. Chronic prosta- 
titis may also be a sequel to chronic posterior urethritis or 
cystitis, with no appreciable acute prostatitis preceding it. The 
gland being predisposed by congestion, it is easily susceptible 
to infection. Any disturbance producing pelvic engorgement, 
irritating injections, continued sexual excesses, masturbation, 
hemorrhoids, concentrated urine, habitual constipation, may 
produce congestion of the prostate. 

The symptoms of chronic prostatitis differ but little from 
those of chronic posterior urethritis. The most marked dif- 
ference is in a burning pain distinctly referred to a point almost 
immediately behind the fossa navicularis. Urination may be 
followed by and defecation associated with an emission of a milk- 
like fluid, which on examination is found to consist of prostatic 
juice, amyloid prostatic bodies, occasionally blood, epithelium 
from the prostate and its ducts, and pus. The pain after urina- 
tion and defecation or either may be severe, lasting sometimes 
for several hours. It may radiate from deep in the perineum to 
the rectum, testicles, and down the thighs, and is aggravated by 
motion or effort of any kind. 

The perineum is tender to touch. Rectal examination of the 
prostate shows it to be irregularly nodulated or asymmetric. 
After massage, the urine contains considerable pus. 

The mind and nervous system suffer perhaps more in chronic 
prostatitis than in any other genito-urinary affection excepting 
seminal vesiculitis. These sufferings are aggravated when ac- 
companied by reduction or loss of sexual desire. The patient 
then becomes markedly neurasthenic and even melancholic, 
with the usual accompaniment of general depressed physical 
tone. 

The constitutional treatment of such cases demands regular- 
ity in meals, consisting of nutritious, bland, easily digestible 
food; systematic exercise, preferably walking in the open air, 
not, however, to the extent of tiring the patient, and a sufficiency 
of sleep. 

Locally, rectal injections of a pint of hot water retained as 
long as possible and followed by a suppository of iodoform and 
codeine phosphate, twice or three times daily, will afford relief. 



108 THE IRRIGATION TREATMENT OF GONORRHOEA. 

Hot sitz-baths twice or three times daily will also aid in the 
treatment. 

Massage of the prostate every second day will empty the 
organ of pus that has accumulated, and will relieve congestion 
if it contains no pus. The most beneficial manner of securing 
this end is by a complete intravesical irrigation with boric acid, 
four per cent., followed by filling the bladder with the same 
solution, after its first washing has been passed out. The 
massage is performed after the bladder has been almost filled 
for the second time. The fluid then passed will be found turbid 
with the substances expressed from the prostate. If the patient 
can stand a third intravesical irrigation, one of silver nitrate 
1:5,000 or 1:3,000, according to his vesical tolerance, may be 
advantageously used (see also Rectal Palpation of the Urethral 
Adnexa). 

Patients with chronic prostatitis are liable to acute intercur- 
rences. These must be treated as suggested for acute prosta- 
titis. 

Retention op ueine is rare in gonorrhoea. It may occur in 
very hyperacute cases, or in those aggravated by alcohol, coi- 
tus, masturbation, irritating injections, or the introduction of in- 
struments. Invasion of the prostate and the presence of even 
large calibre strictures may produce retention of urine in gonor- 
rhoea, by the urethrospasm they are likely to provoke. 

When a patient with gonorrhoea cannot pass urine, he is 
usually in such agony that the history of the case cannot be ob- 
tained. It will be well, before attempting to unload the blad- 
der, to examine the prostate. If the finger inserted into the 
rectum feels the prostate to be enlarged, hot and sensitive to 
touch, the retention is attributable to at least congestion of this 
gland. If the prostate be found normal, any or several of the 
above causes may be at the bottom of the retention. 

The patient should be at once placed in a hot bath, hot 
enemata given him, followed by a suppository of iodoform and 
opium. If these fail to relieve the emergency, the following 
steps for evacuating the bladder may be employed : 

1. Irrigate the anterior urethra with potassium permanganate 
1:6,000 or boric acid four per cent. The solution should be 
at a temperature of between 110° and 120° P. This irrigation 
alone often suffices to relieve the spasm. 



COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 109 

2. After using 750 c.c. (one and a half pints) of either of the 
above solutions, inject one or two drachms of a warm two-per- 
cent, solution of eucaine into the urethra. Hold it there by com- 
pressing the sides of the glans with the left thumb and index 
finger. Stroke the urethra with the right fingers at first gently, 
then with increasing pressure, to force the eucaine solution 
beyond the site of the spasm, which is usually located in the 
membranous portion. 

3. Kemove the nozzle from the irrigator tube and attach in 
its place a sterilized semi-soft French conical, well-lubricated 
catheter. 

4. Insert the catheter, and when its eye is beyond the meatus 
let the irrigating fluid pass through it. 

5. Very gently glide the catheter onward, striving to reach 
the bladder before the entire contents of the irrigator have 
escaped from the urethra. If the catheter in its onward course 
meets an obstacle which it cannot overcome without force, 
withdraw the instrument an eighth or a quarter of an inch and 
endeavor to insert it in slightly different directions until the 
lumen is found. 

6. If the semi-soft catheter fails to enter the bladder, re- 
course must be had to a silver catheter, employing all the pre- 
cautions mentioned above. 

7. When the catheter has reached the bladder, detach the 
irrigator tube and allow about 90 c.c. (three ounces) of urine to 
escape slowly by checking the stream with the finger over the 
mouth of the catheter. When this amount has flowed off, inject 
60 c.c. (two ounces) of four-per-cent. warm boric-acid solution. 
Again allow 90 c.c. to escape slowly from the bladder, and repeat 
the injection of 60 c.c. boric acid. Resume these alternate slow, 
small emissions and injections until the fluid that flows from 
the catheter proves to be clear boric-acid solution. Then in- 
ject 60 c.c. of boric-acid solution and withdraw the catheter until 
its eye is just beyond the compressor. This will be manifest 
by cessation of flow from its mouth. 

8. Ee-attach the irrigator nozzle and allow 250 c.c. (one-half 
pint) of warm boric-acid solution to run through the catheter 
while it is being removed from the urethra. 

9. Urge the patient to retain the boric acid left in his blad- 
der for at least an hour. 



110 THE IRRIGATION TREATMENT OF GONORRHOEA. 

10. If three hours later the patient cannot empty his blad- 
der without assistance, catheterize again as above directed. 
The main purpose of the slowness advocated is threefold : 

(a) The continuous flow of the warm solution through the 
catheter, while it is being passed through the urethra, is in- 
tended, as far as possible, to prevent carrying infection to the 
bladder. At the same time its temperature may aid in over- 
coming the urethral tumefaction and such spasm as may exist. 

(b) Slowly emptying the bladder gives it better opportunity 
to regain its muscular tone, which may be seriously impaired by 
overdistention. 

(c) Rapidly emptying the bladder to relieve retention may be 
followed by dangerous hemorrhage ex vacuo. 

In some very rare cases, great difficulty may be experienced 
in inserting a catheter, when a second emptying of the bladder 
becomes necessary. The question of permanent catheterism 
then arises. It naturally involves the risk of impeding the 
free escape of pus from the urethra and of infecting the bladder. 
Equally its omission may allow the congestion of the urethra 
or of the prostate or both to increase, effectually shutting off the 
outflow of urine, with all its dangers. 

In such a rare case it is advisable to provide continuous 
bladder drainage, with a catheter too small to block the urethral 
discharge. The presence of the catheter in the urethra and 
bladder will serve to reduce the thickening of the urethra and 
of the prostate, if both are congested, as is shown by the free 
voluntary outflow of urine alongside the catheter in a very few 
hours. Repetition of catheterization will then not become neces- 
sary. 

The easiest and safest method of fastening the catheter in the 
bladder is the one we owe to Guy on, 1 whose directions are con- 
densed as follows : 

1. Cut two pieces of firm knitting yarn each one metre 
(about forty inches) long. 

2. Fold them in half, and tie the free ends of each separately. 

3. Place the strings in bichloride or boric-acid solution. 

4. Insert the catheter and so place it that the urine comes 

1 Guyon : Lecons cliniques sur les Maladies des Voies Urinaires, vol. iii., 
Bailliere, Paris, 1897. 



COMPLICATIONS AND SEQUELS OF GONORRHOEA. Ill 



5 &9fc; 



>**£ 



from its mouth in single drops. Watch this dropping for sev- 
eral minutes; if the urine is occasionally emitted in a little 
stream, or if it stops entirely, move the catheter either a trifle 
more deeply into the bladder or an equal distance forward until 
permanent dropping of urine is secured. 

5. Take one of the doubled strings from the antiseptic solution, 
fold it in half again, and tie it firmly around the catheter, exactly 
at the level of the meatus (A) (Fig. 36). Then take its two double 
ends to the side of the penis, hold them together at the coronary 
sulcus (B ; ) and tie another 
knot there. Keep this knot 
at the sulcus (B) exactly 
half-way between the frenum 
and the dorsum of the penis. 
Separate the doubled strings 
and pass them around the 
penis, to be tied in a firm 
knot at the corresponding 
side (B'). The double 
string collar thus tied about 
the neck of the penis must 
not be tight enough to cause 
even inconvenience should 
an erection occur. 

6. Tie the second doub- 
led string (which appears 
as dotted line in Fig. 36) in 
the same manner as the first 
doubled string was attached 

to the catheter. Place the first knot in the second doubled 
string immediately in front of the first string and directly op- 
posite the first knot. Carry both ends of the second string 
to the knot that completed the collar (B ; ). Tie a knot in the 
second string there. Separate the cords that form the first 
string as it makes the collar at each side of the knot and pass 
each end of the second string through the separations. Tie 
them in a knot upon the first string's knot (B'). Pass the two 
ends of the second string around the neck of the penis as those 
of the first string were passed, but in the opposite direction, 
forming another collar. Close the collar by a knot at B and 




Fig. 36.— Fastening Catheter into Bladder. 
(Guyon : " Voies Urinaires.") 



112 THE IRRIGATION TREATMENT OF GONORRHOEA. 

fasten the strings there in the same manner as they were fast- 
ened at B'. 

7. Take up a bunch of hair at about an inch from the root 
of the penis (C) and twist it into the shape of a moustache. 
Lay the string alongside of the penis like a rein, and where it 
touches the moustache, without stretching or moving the penis 
from the exact median line ; tie it firmly about the root of the 
moustache. As this knot will envelop the base of a pyramid 
of hair, it will be likely to slip off; therefore double the mous- 
tache upon itself and with another knot fix the rein in place. 




;^r~ -,^s>^« 






- '-»***>-,«>■*■*■ - - . 




y-Rbussel; • 





Fig. 37.— Drainage Into Urinal. 
(Guyon : " Voies Urinaires.") 

Eepeat this procedure with the other rein that hangs from the 
collar at B', attaching it to C, opposite the first moustache. 

After so fastening the catheter in place, the condition of the 
bladder must decide whether continued drainage or interrupted 
evacuation should be employed. In a general way it may be 
laid down that if the bladder is infected, continued drainage with 
continual washing will be necessary ; if the bladder is not in- 
fected, interrupted evacuation is easily obtained by plugging the 
mouth of the catheter with a wooden spigot. This spigot can 
be removed each time it becomes necessary to empty the bladder. 

Continuous drainage of the bladder is best accomplished by 
attaching a rubber tube eight inches long to the mouth of the 
catheter, and inserting it into the bottom of the tube (D) of a 
Duchastelet antiseptic urinal, containing a solution of bichloride 
1 : 1,000. A similar quantity of the same solution may be poured 
into the bowl of the urinal, through its opening C, after the 
urinal is placed between the patient's thighs. The purpose of 
placing the urinal between the patient thighs is to protect the 



COMPLICATIONS AND SEQUELS OF GONORRHOEA. 113 

bed, to allow the patient some latitude in motion and to pre- 
vent the bending of the penis and the catheter it contains, thus 
insuring its continuous free action. 

Whether it is determined to employ continuous or inter- 
rupted vesical evacuation, the penis should be " dressed " in the 
manner laid down by Guyon. This dressing is made with three 
pieces of salicylated or carbolated gauze 25 cm. (about ten inches) 
square. These are folded in half, from one angle to its opposite 
one, making a triangle of six layers of gauze. The base of this 
triangle is passed close to the penoscrotal angle, and the two 
angles at the base are doubled over the penis so that the one 
projecting to the right of the penis reaches the left side of the 
pubis, where the strings holding the catheter are tied to the 
hairs (see Fig. 37). It is firmly attached to this spot with 
the string that was left hanging there. The angle of the gauze 
triangle projecting from the left side of the penis is folded over 
to the right tied moustache and attached firmly to it. The 
moustache strings are then cut off. The penis is thus com- 
pletely enveloped by the gauze. To prevent its slipping up- 
ward, the angle around the catheter is tied to it by another 
piece of string. 

While it is undoubtedly a grave violation of surgical prin- 
ciples to insert any instrument into an acutely inflamed urethra, 
I must confess that I was driven to it in three cases. In each 
of these the urethra was lacerated from attempts to pass cath- 
eters for the relief of retention. No aspirator or trocar was 
within several hours' reach, and the patients w r ere in acute suf- 
fering, with high fever. I was fortunate enough to get cathe- 
ters into these bladders. One remained four hours, another six 
hours, and the third eighteen hours. Naturally all possible 
antiseptic precautions were taken. In none of the three cases 
did vesical infection result, nor was the gonorrhoea materially 
aggravated from the use of the catheter. 

Should it be impossible to pass a catheter, after the prelimi- 
nary efforts (hot baths, etc.) have failed, it will be necessary to 
either aspirate or evacuate part of the bladder conteuts by a 
trocar through the suprapubic space. In many cases it will be 
found that after removal of perhaps one-fifth of the retained 
urine, the patient will be able to empty the remainder through 
the urethra, owing to relief from the tension. 
8 



114 



THE IRRIGATION TREATMENT OF GONORRHOEA. 



If prostatic congestion causes the retention, catheters of the 
Mercier curve will be found most useful. Guyon suggested 
various lengths of beaks and angles at which the beaks are at- 
tached to the shafts for easier introduction and more comfort- 
able retention, according to the degree of prostatic swelling. 
Those most frequently used are shown in Fig. 38. Their press- 
ure upon the prostate proves valuable, while placing the reten- 
tion of urine under control. When, however, evidence of pus 




Fig. 38.— Guyon Beaks of Mercier Catheters. 

formation in the prostate presents, the abscess cavity must be 
promptly emptied. 

Eheumatism (gonorrhceal).— A somewhat extensive study of 
the literature of gonorrhoea makes Bransford Lewis appear the 
first, at least among American writers, to show that infection of 
the posterior urethra is far more frequent than is ordinarily 
assumed. This author, 1 in an interesting and instructive mono- 
graph, shows that posterior urethritis is almost invariably pres- 
ent in every case of prolonged or severe gonorrhoea. He further 
asserts that the gonococci, instead of gradually progressing along 



1 Lewis: "The Role of Posterior Urethra in Chronic Urethritis." Read 
before the American Association of Genito-Urinary Surgeons, June 21st, 1893 r 
Medical Record. 



COMPLICATIONS AND SEQUELAE OF GONORRHCEA. 115 

the urethral mucosa to penetrate eventually the compressor in 
two or more weeks after the onset of the disease, are promptly 
carried back through the lymphatics. About the same time 
Eona, of Budapest, made similar assertions, but his thoughts 
on the subject were presented more tentatively than were the 
findings of Lewis. 

The facts exposed by these authors emphasize the need of 
intravesical irrigations (see page 29) even when gonorrhcea 
seems to arlect only the anterior urethra. At all events, experi- 
ence shows that when irrigations are properly used, the posterior 
urethra, if it does not escape invasion, does not show any mani- 
festations of the disease. 

Accepting the above author's most reasonable explanation of 
the etiology of posterior gonorrhcea, it is not surprising that 
remote regions and organs are often the site of the deposit of 
gonococci. As mentioned elsewhere, there is hardly a soft 
tissue of the organism in which modern investigation has not 
been able to demonstrate gonorrhceal infection. 

Among the manifestations of remote gonorrhceal invasion, 
rheumatism is at present the most frequently recognized. In 
the majority of cases it affects only one joint, and among these 
oftenest the knee. Less frequently the ankle, wrist, and elbow 
are the site of gonorrhceal rheumatism. 

Gonorrhceal rheumatism is not distinguishable from rheu- 
matism of other origin. Neither does its appearance, while a 
patient has gonorrhoea of the urethra, conjunctiva, vagina, or 
rectum, prove that it is gonorrhceal. The fever and sweating 
are usually higher in ordinary rheumatism, except when the af- 
fected joint becomes the site of pus formation. 

When rheumatism of any kind complicates gonorrhoea it 
should be treated as rheumatisms usually are. While this is 
being done, irrigations must not be interrupted, so that the 
gonococci, which may be the provokers of the rheumatism, be 
eliminated as soon as possible. 

Skin Diseases.— Taylor says that he has many times seen 
patients with acute and declining gonorrhoea attacked by erup- 
tions resembling scarlatina, measles, oedematous erythema, and 
urticaria. In some instances he did not find that gastric dis- 
turbances due to antiblennorrhagics was the exciting cause. 

Many other eminent writers have reported such cases. 



116 THE IRRIGATION TREATMENT OF GONORRHOEA. 

Among these Finger 1 described three of gonorrhoea and cystitis 
complicated by purpura rheumatica. 

Buschke, 2 grouping his own observations and those of other 
writers, " first mentions simple erythema, which usually appears 
in connection with gonorrhoeal rheumatism, epididymitis, or 
other localized inflammatory complication. Cases have been 
recorded, however, of a febrile erythematous rash in gonorrhoea. 

The second group is made up of urticaria and erythema 
nodosum. The fact that the latter form of eruption may com- 
plicate a febrile gonorrhoea shows that it is not a mere appanage 
of polyarthritis, but is most likely due to the direct action of 
the gonococcus. 

The third division of Buschke is made up of hemorrhagic 
and bullous eruptions. 

The fourth and last division consists of the hyperkeratoses, 
and has hardly before been mentioned in literature. Buschke 
has found a record of four cases which he considers in this con- 
nection. In a case originally described by Chauffard, for ex- 
ample, there were horny thickenings upon the feet, back, penis, 
and insides of thighs, accompanying a general gonorrhoeal in- 
toxication. 

Authorities are still at odds as to the explanation of these 
cutaneous manifestations of gonorrhoea, and several widely dif- 
fering views are ably*maintained in controversy." 

My own studies of skin complications of gonorrhoea began 
after I had commenced the use of irrigations. None of the 
cases so treated from the inception had any dermal trouble. 
Many of those which had been treated before by internal medi- 
cation or hand injections or both, had skin diseases. In those 
in which the skin affections could not be traced to digestive dis- 
turbances from antiblennorrhagics, they appeared to have no 
connection with gonorrhoeal infection, .except in some of those 
conditions mentioned under neuroses. 

Steictuee. — Wossidlo 3 defines urethral stricture as " a nar- 

1 Einger : " Ueber Purpura rheumatica als Komplication blennorrhagischer 
Prozesse." Wiener medicinische Presse, Nos. 9, 10, and 11, 1880. 

2 Buschke: Archiv fur Dermatologie und Syphilis, Band xlviii., No. 2, 
most admirably excerpted by the Medical Review of Reviews, July 25th, 1899. 

3 Wossidlo: Die Stricturen der Harnrohre und ihre Behandlung, Nau- 
mann, Leipzig, 1898. 



COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 117 

rowing of the urethral lumen and reduction of its normal dila- 
tability, produced by organic changes in the urethral walls." 

Such changes are usually brought about by a gonorrhoea 
allowed to go on to chronicity through lack of proper treatment 
or care. Congenital strictures, however, and those provoked 
by traumatisms (such as the passage of a rough stone) may 
complicate gonorrhoea as seriously as can acquired strictures. 
They can, moreover, by the same cicatricial tendency to con- 
traction, produce all the disastrous results that may follow the 
latter. Infantile lithiasis, evidenced by painful urination and 
purulent discharge, containing no gonococci and afterward for- 
gotten, may often be the cause of presumed congenital stricture. 

When stricture from internal or external causes complicates 
gonorrhoea, the disease will persist ordinarily until the stricture 
is cured. Stricture itself is too vast a subject to be even outlined 
in a small effort like this ; its influence on gonorrhoea, which is 
prone to aggravate a pre-existent stricture and to produce new 
coarctations, is daily evident. 

The presence of stricture in no wise modifies the treatment 
of gonorrhoea by irrigations. When the acute manifestations 
of gonorrhoea have yielded, the stricture or strictures must re- 
ceive attention, as will be sketched under the head of Chronic 
Gonorrhoea. 

Traumatisms of the Urethra. — The injuries of the urethra 
that may complicate gonorrhoea are, besides those mentioned 
under Foreign Bodies and Hsematuria, such as may be pro- 
duced by faulty circumcision. 

M. A. Wasiliew, x citing Bergson, Ploss, and Joly, shows that 
this operation was performed by the ancient Egyptians and 
Phoenicians. To-day ritual circumcision is done only by Jews, 
Mohammedans, and a number of savage tribes. 

The American and Bussian Jews cut off the preputial in- 
tegument with a small knife, and tear the mucous fold with the 
fingers. The knife may injure the glans and the part of the 
urethra it contains; efforts to split a firmly adherent mucosa 
with the pulp of the index fingers and thumb nails may tear 
open the fossa. 



1 Wasiliew : Die Traumen der mannlichen Harnrohre, Hirschwald, Berlin, 
1899. 



118 THE IRRIGATION TREATMENT OF GONORRHOEA. 

In Germany and Hungary, so I am informed, many ritual 
circumcisers maintain the right thumb nail long and trimmed 
for the operation; others use a silver ring-shaped attachment 
with a flat, finger-nail-like projection, to slip over the thumb 
when the operation is to be performed. 

At least one of the native tribes, Los Lacantunes, of that 
region of Guatemala that has been but partly explored, use an 
obsidian for the same purpose. 

Ramon Guiteras 1 is of the opinion that stricture of the 
meatus is most frequent with those circumcised in infancy. 
Since having attention called to this point, I searched my 
records and found that I performed far more meatotomies on 
those circumcised in early life than on others. If this is not 
a mere coincidence, it is hardly explicable by nature contracting 
the meatus to protect the urethra. It seems more likely to be 
attributable to the crude methods employed by the Mohelim or 
Mauhelim (ritualistic circumcisers). 

Every physician who has circumcised many infants knows 
that the lips of the meatus are found pouting. As the ritualistic 
circumcisers cut or pinch off the foreskin close to the meatus, 
it is readily appreciable how they can remove with it a part of 
the pouting lips. The resulting cicatrix naturally contracts 
and so produces the stricture. Among those who present no 
contraction of the meatus, slight radiating marks suggest the 
possibility of a small tip of the meatus having been removed. 

Disregard for asepsis in ritualistic circumcision has caused 
many, and among them devout Jews, to inveigh against the op- 
eration. Erysipelas, syphilis, and tuberculosis are frequently 
reported in support of this objection. In France a sanitary law 
was passed at the beginning of 1899 prohibiting circumcision, 
except it be in the presence of a physician. While the intent 
of this law is manifest, its execution is likely to fall far short 
of its purpose, as must be evident to those who from sad ex- 
perience know the difficulty of securing asepsis in even trained 
assistants and nurses. 

Regarding injuries to the urethra from circumcision, Sascke 2 

1 Guiteras : "A Review of the Principal Features of Urethral Stricture." 
Medical Review of Reviews, January 25th, 1899. 

2 Sascke : " Betrachtliche Verletzung der Harnrohre." Schmidt's Jahr- 
bucher, vol. lv., 1847. 



COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 119 

reports a young Jew whose anterior half of the glans was miss- 
ing. The meatus was at the lower surface, and behind this a 
second orifice emitted the urine. It seems, however, that in thi3 
case the mutilation complicated a pre-existing deformity. 

A patient referred to me for chronic gonorrhoea had had 
over four-fifths of the right half of his glans torn off during 
ritualistic circumcision. The left side of the fossa was exposed. 
From the right coronary margin three fleshy projections hung. 
The consequence of this deformity doubtless contributed in 
making his gonorrhoea most persistent. 

A most aggravated case of urethral traumatism from ex- 
ternal violence was in a young man whose penis a prostitute 
had bitten while, as he said, both were drunk. Singularly 
enough, the upper surface of the middle third of the penis 
showed only slight bruises from the teeth; the lower central 
incisors had evidently been sharper, for they penetrated the 
urethra and had sunk into the corpora cavernosa. Permanent 
catheterization was at once employed, but as the wound soon 
manifested syphilitic infection attempts at repair have thus far 
proved futile. 

Injuries to the urethra from within, such as follow violent 
instrumentation, false passages, tears of the mucosa, may com- 
plicate gonorrhoea. When irrigations have reduced the inflam- 
mation and discharge to a minimum, these injuries should be 
sought by the urethroscope and treated as their especial char- 
acter may require. 

Vesiculitis Seminalis (Gonocystitis).— If Fuller 1 had done 
nothing else than develop the pathology and rational treatment 
of inflammation of the seminal vesicles, his studies of this dis- 
ease alone would suffice to place the profession under deep ob- 
ligations to him. 

With a view to refreshing memory on the precise location of 
these organs, whose infection is far more frequent than ordi- 
narily recognized, a schematic drawing may be borrowed from 
Stewart, 2 elucidated with Lewis' 3 concise description of the 
seminal vesicles which is here condensed : The vasa deferentia 



1 Fuller : Disorders of the Male Sexual Organs, Lea, Philadelphia, 1896. 

2 Stewart: Diseases of the Urethra. William Wood & Company. 

3 Lewis: "Seminal Vesiculitis as an Obscure and Elusive Disease." 
Medical Age, June 25th, 1897. 



120 



THE IRRIGATION TREATMENT OF GONORRHOEA. 



carry the spermatozoa from the testicles, through the inguinal 
canals, into the pelvic cavity, converging behind the bladder and 
almost touching each other behind the prostate. The seminal 
vesicles lie against the posterior surface of the bladder, just 
beyond the convergence of the vasa, which conduct the sperma- 
tozoa into the vesicles. There the fluid secretion of the vasa 
keeps them alive. At opportune moments (coitus or nocturnal 
emission) the spermatozoa are thrown out of the vesicles through 
the ejaculatory duct, which perforates the prostate, into the pos- 




Fig. 39.— Location of the Seminal Vesicles (from Stewart's " Diseases of the Urethra "). 

terior urethra, where they are mixed with prostatic juice, and 
whence they are ejected by the spasmodic contractions of ejacu- 
lation. 

It consequently is clear that the finger inserted into the 
rectum will feel the seminal vesicles immediately above the 
prostate and projecting to either side of the bladder. In health, 
however, these soft little pouches are difficult and often impos- 
sible to find. 

In view of the fact that the ejaculatory duct is so short and 
almost straight, it is strange that seminal vesiculitis does not 
more frequently complicate gonorrhoea. As, however, acute 
gonocystitis, as Gouley aptly calls the disease, fortunately tends 
to resolution, it may be overlooked in very many gonorrhoeas. 



COMPLICATIONS AND SEQUELAE OF GONORRHOEA. 121 

Moreover, the close resemblance of its symptoms to those of 
posterior urethritis and prostatitis may account for its relatively 
rare discovery. If every patient 'with gonorrhoea were subjected 
to digital examination per rectum, infection of the seminal ves- 
icles would be better understood and its often disastrous con- 
sequences avoided. 

The symptoms may be ushered in by a mere sense of weight 
in or about the perineum. This soon changes to dull or throb- 
bing pain in this region and that within the anus and the bladder. 
Rectal and vesical tenesmus may become very intense. All 
these symptoms increase while urine accumulates in the bladder; 
the pain then may be referred to the region of the glans or the 
root of the penis, or both. The constitutional disturbance is 
often quite marked; anorexia, even nausea, may accompany the 
beginning of the disease, while decided chills and fever may 
cause an error of diagnosis. 

Certainty of differentiation, principally from posterior ure- 
thritis, is obtainable only by rectal examination. The presence 
of a swollen, painful prostate should not be accepted as conclud- 
ing a diagnosis. The ringer passed beyond this gland should 
seek the seminal vesicles which, if involved, will be found 
" much enlarged in all directions in the shape of a distended 
leech, hot, brawny, and exquisitely tender " (Taylor). 

Further development of the disease can cause a pulpy con- 
fluence of the vesicles of both sides, rendering their delineation 
impossible. They may then appear as if overhanging the pros- 
tate like a large, flabby mass. 

With the progress of vesiculitis the patient presents all the 
appearances of severe illness associated with acute sufferings. 
The pains in the perineum, rectum, and bladder become intensi- 
fied, and extend to the sacrum, the coccyx, the hip-joint, down 
the sciatic nerve, sometimes up to the diaphragm, making even 
breathing painful. The local pains are increased by urination, 
which is frequent ; but the pain, if there is any after urina- 
tion, is not so severe nor so prolonged as that of posterior 
urethritis. 

Examination of the urine may be misleading, unless speci- 
mens of the first morning urine or that passed at the end of 
defecation is used. At other times the urine may appear normal . 
The properly selected specimen will contain, according to the 



122 THE IRRIGATION TREATMENT OF GONORRHCEA. 

intensity of the involvement, pus corpuscles, red blood corpus- 
cles, epithelia from the ejaculatory ducts, epithelia from the 
prostate, mucous casts, and spermatozoa. Among the latter 
many a one will be found with a rounded enlarged head whose 
pellucidity has changed to a granular appearance, making the 
diseased spermatozoon look like a tailed pus corpuscle. If the 
gonocystitis is gonorrhceal, gonococci will be present in the 
specimen. The greater the chronicity of the case, the greater 
will be the number of the fat globules. Fuller (op. cit.) holds 
that in about one-third of the cases of seminal vesiculitis the 
disease is tuberculous. While all deference is due to Fuller's 
wide researches, this large number of tuberculous invasions of 
the seminal vesicles does not coincide with the experience of 
others, that of the present writer included. Still, Fuller's 
warning should never be left out of mind. 

Heitzmann {op. cit.) always finds prostatic epithelia with 
microscopic evidences of gonocystitis, from which he deduces 
that the prostate is inflamed when the seminal vesicles are. For 
self-evident reasons (see Fig. 39, page 120) it would be practically 
impossible for the prostate to escape such infection. But as 
the disease of the vesicles may overshadow the latter, it may 
elude observation. 

Defecation, in seminal vesiculitis, is often as painful as is 
urination. It may be associated with intense tenesmus of the 
rectum and of the bladder. 

Unless sleep is disturbed by painful erections or emissions, 
it may be very prolonged. Despite its length, the patient is as 
fatigued when he awakes as when he retired. 

If the patient has nocturnal emissions, they may be bloody 
or of a chocolate color, from the admixture of blood. 

When the ejaculatory duct is not firmly agglutinated, the 
seminal vesicle may be emptied of much or all of its pus by 
strippings through the rectum. The remainder of the treat- 
ment is necessarily similar to that advised for prostatitis. 

If acute vesiculitis does not go on to resolution or is not re- 
lieved by treatment, it may go over into chronic gonocystitis or 
abscess may form, with all the dangers of invasion of other 
structures. 

Abscess of the seminal vesicles should be promptly emptied 
through the perineum or the rectum. In making the long free 



COMPLICATIONS AND SEQUELS OF GONORRHOEA. 123 

incision through the anterior rectal wall for extensive abscess, 
as advised by Gouley, the cavity should be carefully packed and 
asepsis of the region observed as cautiously as possible. 

An attempt to study chronic seminal vesiculitis in such brief 
form as would be admissible here could not but prove mislead- 
ing. The reader is therefore referred to the more exhaustive 
works of Fuller, Gouley, Taylor, "White and Martin, and others 
for clear, complete discussion of the subject. 

This perfunctory disposal of chronic seminal vesiculitis 
should not lead to a light consideration of the disease. The 
vast array of symptoms, direct and reflex, which it produces 
makes it worthy of most serious attention, as do the dangers to 
which it exposes the patient. Moreover, when due to gonor- 
rhoea, as it very often is, it will explain many cases of apparently 
frequent recurrences of the disease. Indeed, when a presumably 
fresh gonorrhoea presents in less than two or more than ten days 
after coitus, the physician would be derelict in his duty if he 
did not interrogate the seminal vesicles. 

Ueethbo-Pbostatic Infection by the Nogues- Wassebmann 
Diplococcus.— While this form of genito-urinary infection is 
not a complication of gonorrhoea, it is outlined here for con- 
venience of differentiation. This urethro-prostatic trouble may 
be mistaken for cystitis, urethrocystitis, and prostatitis. Paul 
Nogues and Melville Wassermann 1 describe the etiological 
microbe which they discovered as resembling the gonococcus 
in form, dimensions, staining and decolorization by Gram's 
method so closely that many authors would not hesitate to class 
it with Lustgarten and Mannaberg's pseudo-gonococci. They 
insist that all the diplococci so grouped can be differentiated by 
careful examination. 

Nogues and Wassermann describe the symptoms of urethro- 
prostatic infection by their micro-organism in a case from 
Guyon's service in the Hopital Necker: 

The patient, aged 42, had no disease except syphilis, con- 
tracted many years ago. Eighteen months before being treated 
at the Necker, he had had vague pains in the region of the peri- 
neum and of the anus. Twelve days subsequently he observed 

1 Nogues et Wassermann : "Infection Urdthro-Prostatique, due; a un micro- 
organisme particulier." Annales des Maladies des Organes Gtenito-Urinaires, 
July, 1899. 



124: THE IRRIGATION TREATMENT OF GONORRHOEA. 

an oozing from the urethra. This oozing never assumed the 
proportions of a true blennorrhoea, he had no painful urination 
nor nocturnal erections. The only functional symptom was the 
anal pain mentioned above. For six months he was treated by 
washings with boric acid and santal oil internally. The next 
physician he consulted diagnosed prostatitis and employed irri- 
gations of potassic permanganate and prostatic massage. No 
change in the condition resulted in the beginning ; soon, how- 
ever, vesical^ manifestations appeared — the patient urinated 
every two hours during the day and four times at night. In 
this condition he sought Professor Guyon's advice. The 
urethral discharge was then minimal, but a few slightly colored 
spots stained the shirt ; the urine was acid and clear, but the 
first urine emitted contained numerous dense and heavy fila- 
ments. The urethra was found in good condition, the bladder 
of nearly normal capacity. The prostate was in almost com- 
plete health, but the urine voided immediately after massage 
was decidedly turbid. In this specimen Nogues and Wasser- 
mann found their microbe. 

After an instillation of silver nitrate into the prostatic por- 
tion by Guyon's method, the urine almost recovered its trans- 
parence; very careful microscopic examination did not reveal 
any bacteria whatever, and two tubes of agar and of bouillon 
sown with the specimen remained sterile. The cure was verified 
two weeks later by a second bacteriological examination which 
gave a negative result. 

The authors, after most exhaustive histological and bacterio- 
logical series of experiments, including cultures on all accepted 
media of the turbid urine with an abundant whitish sediment, 
sum up the characteristics of their microbe as follows : 

A diplococcus, within and outside the leucocytes, not in 
specific grouping, readily decolorizable by Gram's method; 
easily and abundantly culturable on all the ordinary media ex- 
cept on potato; does not liquefy gelatin, indifferent in the 
presence of oxygen and of rapid growth in anaerobic condition ; 
apparently with no power to decompose urea. 

They conclude that the diplococcus they describe is the in- 
fectious agent of a form of urethro-prostatitis and that it can be 
thoroughly differentiated from the gonococcus by culture. 



CHRONIC GONORRHOEA. 125 



VIII. CHRONIC GONORRHOEA. 

Under the treatment pursued before irrigations were estab- 
lished, six weeks was deemed the duration of an acute gonor- 
rhoea. If it proceeded beyond six weeks, it was considered to 
have gone over into a chronic condition. This chronicity, 
however, was often associated with all the symptoms of the 
acute attack. 

Goldberg's statistics (quoted on page 1) compiled from the 
works of all who wrote on irrigations, whether approvingly 
or disapprovingly, show that ninety per cent, of the patients re- 
cover within fourteen days. It is therefore equally proper to 
hold that a case of gonorrhoea not entirely cured within two 
weeks must be considered a chronic clap. 

Janet, to whom all the credit is due for popularizing the 
irrigation treatment, advises a second series of irrigations after 
the first series, when that has not succeeded. The second series 
of irrigations with solutions of potassic permanganate as advo- 
cated by Janet is as follows : 

First day, first visit, Anterior irrigation 1 : 3,000 

First day, 7 p.m. Anterior irrigation 1 : 6,000 

Second day, 9 a.m. Intravesical irrigation 1 : 4.000 

Second day, 7 p.m. Anterior irrigation 1 : 4,000 

Third day, 7 p.m. Anterior irrigation 1 : 2,000 

Fourth day, 9 a.m. Intravesical irrigation 1 : 3,000 

Fourth day, 7 p.m. Anterior irrigation 1 : 2,000 

Fifth dav 7pm i Intravesical irrigation 1 : 3,000 

( Anterior irrigation 1:1 ,000 

Sixth day, 7 p.m. Anterior irrigation 1 : 1,000 

Seventh day, 7 p.m. Anterior irrigation 1 : 1,000 

Eighth day, 7 p.m. i Intravesical irrigation 1 : 3,000 

( Anterior irrigation 1 : 1,000 

In offering the above formulary, no thought is conveyed that 
it will cure every chronic gonorrhoea. Even if the clap is un- 
complicated, the solutions may have to be materially modified 
to meet the individual peculiarities of each case. The solutions 
advised, however, meet the average cases. 

Furthermore, this formulary will serve admirably in most 
gonorrhoeas which appear without acute manifestations (chro- 
niques d'emblee, Guiard) and which are so often erroneously 
called "light attacks." 



126 THE IRRIGATION TREATMENT OF GONORRHOEA. 

The majority of cases, however, require most scrupulous 
search for the conditions that cause their progression into 
chronicity. 

In an effort like this none but the barest outlines of pathol- 
ogy can be sketched, and indeed, none of these can find place 
except those essential to an intelligent comprehension of the 
treatment advocated. The writers who have labored and are 
laboring so industriously and well in this, the most important 
department, of genito-urinary diseases, can receive but scant 
attention. No lack of appreciation is conveyed thereby. As 
Oberlaender 1 said five years ago: "The literature of chronic 
urethritis has grown to monstrous proportions." The additions 
to this literature since then are if anything greater in number than 
those which preceded Oberlaender's comment; hence the hope- 
lessness of attempting even approximate justice to the authors. 

The principal conditions that predispose a patient to the 
establishment of a chronic gonorrhoea are reduced vital resist- 
ance, lax urethral mucosa, phthisis, diabetes, phimosis, agglu- 
tination of the prepuce to the glans, tight meatus, a narrow 
urethra, deformities of the glans, para-urethral fistuhe and re- 
sidual defects from former gonorrhoeas, " be they ever so minute 
and often not evident to the inexperienced urethroscopist " 
(Oberlaender). In many instances none of these predisposing 
elements are found to explain the progress into chronicity; in 
any given case in which this occurs, cure is not likely to be ob- 
tained until the cause is found and removed. 

The causes of the transition of gonorrhoea into the chronic 
state, are summed up by Guiard 2 in his brilliant and exhaustive 
work on the subject. With slight modification from this author, 
they may be cited as : (1 ) congenital or acquired deformities ; (2) 
the patient's constitutional condition; (3) misdirected or in- 
sufficient initial treatment; (4) infractions of hygienic precau- 
tions ; (5) over-treatment. 

The two first-named have been briefly mentioned above. 
They are discussed somewhat more in detail in Chapter VII. 
(Complications of Gonorrhoea). 

Oberlaender: "Die chronischen Erkrankungen der mannlichen Harn- 
rohre." Klinisches Handbuch der Harn- und Sexualorgane, vol. iii., Vogel, 
Leipzig, 1894. 

2 Guiard : Les urethrites chroniques chez 1'homme, 1898, Rueff, Paris. 



CHRONIC GONORRHCEA. 127 

As outlined under the head of acute gonorrhoea, irrigations 
to be effective, must be promptly and energetically instituted 
as soon as possible after inception of the disease. But irriga- 
tions will certainly be misdirected and thwart the object in 
view if the physician were to mistake force and violence for 
promptness and energy. The column of fluid, if bruskly sent 
into an exquisitely inflamed urethra, cannot but damage it; 
lesions can easily be caused thereby, directly inviting invasion 
of the deeper structures and thence of the adnexa and the entire 
organism. Therefore, while all uncomplicated and most com- 
plicated gonorrhoeas must and should be treated by the general 
practitioner, none should touch them save those who are char- 
acterized by innate and carefully cultivated delicacy of manipu- 
lation. Only those so endowed are able to avoid misdirecting 
even the best intended efforts. 

Insufficient initial treatment is likely to obtain in the hands 
of physicians whose delicacy of touch is above criticism, but 
who lack adequate firmness of purpose. While these will not 
sin by injuring the inflamed urethra they, through timorousness, 
are prone to allow the disease to gain mastery over the infected 
region. This extreme is quite as reprehensible as the other. 

An exceedingly frequent element for the production of 
chronic gonorrhoea, entirely beyond the physician's responsi- 
bility, is in the hygienic and dietary infractions which patients 
commit. In Chapter VI. (Constitutional and Accessory Treat- 
ment) an endeavor is made to outline the hygienic and dietary 
precautions that are necessary for the successful treatment of 
gonorrhoea. If the physician, for any reason, cannot obtain 
such control over his patient that the latter will follow these sim- 
ple instructions or appreciate the dangers of their infraction, he 
will wisely recommend to him the study of James Foster Scott's 1 
book. Should the patient's inferior intelligence or lack of ap- 
plication not permit him to grasp the value of Scott's excellent 
work, he may be advised to read a small effort in the same 
direction. Its author 2 will not object if his name is erased 
from the article before it is handed to the patient. 

1 Scott : The Sexual Instinct ; Its Use and Dangers as Affecting Heredity 
and Morals, Treat, New York, 1899. 

2 "Advice to Gonorrhceai Patients." Philadelphia Medical Journal, July 
8th, 1899. 



128 THE IRRIGATION TREATMENT OF GONORRHOEA. 

Excessive treatment cannot only assure a gonorrhoea becom- 
ing chronic, but also tends to perpetuate a chronic clap indefi- 
nitely. In Chapter XIV. (The Proofs of Cure of Gonorrhoea) 
the indications for discontinuance of treatment are detailed. 

The local pathological conditions which maintain a chronic 
gonorrhoea have been and are made the objects of special in- 
vestigations by an immense array of learned men. To even 
quote their names and outline their results would require a 
large volume. 

For the general practitioner's purpose it may suffice to be- 
gin the study of chronic gonorrhoea by attaching its cause to : 
(1) epithelial disturbance; (2) infiltration of the mucosa; (3) in- 
volvement of the urethral glands ; (4) infection of the adnexa. 

While precise distinction of the three first-mentioned condi- 
tions is obtainable only by the urethroscope, it can hardly be 
'expected that any but those with a very large general practice 
will avail themselves of this instrument of precision. Those 
who desire to instruct themselves in urethroscopy will find 
elementary outlines thereof in Chapter XIII. (Urethroscopy). 

A study of the symptoms of chronic gonorrhoea is, however, 
open to even the least experienced. An effort will be made to 
depict those that are most directly related to therapeutic sug- 
gestions. For easy reference they are arranged in alphabetical 
order. Necessarily, with a view to differentiation, this list must 
include some symptoms not due to chronic gonorrhoea. 

Absence of Symptoms — see Chapter XIY. (Proofs of Cure of 
Gonorrhoea). 

Appaeent Aspermia.— Quite a number of patients complain, 
long after external evidences of gonorrhoea have passed off, that 
they experience little or no sensation at the conclusion of the 
sexual act, no matter how prolonged it was. When withdrawing 
the penis at the feeble conclusion of the act, nothing is seen to 
escape from the meatus. Manifestly, unless the case be one of 
true aspermia, swelling of the posterior urethra directs the 
semen into the bladder, instead as normally, through the com- 
pressor. The next urination then carries with it the semen that 
should have been forcibly ejected in coitus. 

Some of these patients, who are called " trompeurs " (cheat- 
ers) in French literature, will confess to having employed arti- 
fices to prolong the sexual act or to prevent pregnancy. These 



CHRONIC GONORRHCEA. 129 

artifices embrace digital compression of the urethra, constriction 
at the peno-scrotal juncture by a rubber band, or a species of 
mental coercion by means of which the orgasm is arrested just 
before ejaculation. The first urine passed after such coitus will 
be found to contain an abundance of semen. 

Defecation and Urination Drop. — Very many patients have 
no discharge whatever, but during or after defecation or after 
urination a thick white drop appears at the meatus. The man- 
ner in which this drop appears at once suggests a urination — 
or defecation — spermatorrhoea. Indeed, these ma}' coexist with 
the manifestation which I have named as above. 

Like urination — or defecation — spermatorrhoea, this drop is 
sometimes attributed to expression of a diseased prostate or 
posterior urethra, by the pressure of lumps of hard faeces upon 
these organs in their passage through the lower rectum. The 
anatomical relations of this region prevent a faecal bolus, which 
can at all pass the anus, from exercising sufficient pressure upon 
the prostate or posterior urethra to expel their secretions. 
The faecal mass, however, if hard, stimulates voluntary contrac- 
tions of the rectal and urethral detrusors, and these, by forcible 
compression of the prostate and posterior urethra, cause them 
to yield some of their contents. 

Macroscopically, these drops differ from those of spermator- 
rhoea in not proving tenuous — i.e., they cannot be drawn out 
in such long filaments. Moreover, they dry in concretions re- 
sembling phosphatic calculi. When fresh, and pressed or 
rubbed between two cover-glasses they convey a sensation as if 
they contained very fine sand. 

Microscopically, these drops show pus in minute quantity, 
much mucus, epithelium, and occasionally gonococci. The grit- 
like substance has the appearance of little globules, resembling 
cocci. If acetic or nitric acid is added to them, they dissolve 
with the escape of bubbles of gas. 

If spermatozoa are found, the case may be one of pure urina- 
tion or defecation spermatorrhoea ; their presence, however, does 
not exclude the coincidence of gonorrhceal prostatitis or posterior 
urethritis. 

Discharge. — In chronic gonorrhoea the discharge may vary 
from a slight, glairy excess of moisture, expressible to the meatus 
with difficulty, to free, continual, or intermittent discharges. 
9 



130 THE IRRIGATION TREATMENT OF GONORRHOEA. 

The discharge, whatever its character, may be the only symp- 
tom which the patient observes. Some patients are singularly 
indifferent to this manifestation of disease when it gives them 
no inconvenience beyond filthiness; the majority, however, are 
mentally distressed, and in consequence physically disturbed, 
by an excess of moisture that does not even agglutinate the 
meatus. Whether this is on a purely aesthetic score or due to a 
specific lasting influence of gonococci toxins on the nervous 
system, is one of the questions neurologists still have to solve. 

Whatever the character of the discharge, its contents and 
origin must be ascertained. Many microscopical examinations 
may be made without discovering any noxious bacteria. This 
does not entitle the physician to assert that none exist in the 
patient's genital apparatus (see Chapter XIV., Proofs of Cure 
of Gonorrhoea). Whether gonococci, with or without other 
bacteria, present in the slight or copious, permanent, intermit- 
tent or recurrent discharge, or if none are found, the origin of 
the discharge, i.e., the diseased region or regions and the char- 
acter of the disease, must be ascertained. The discharge itself 
is not characteristic of its source. While it can be determined 
by the kind or kinds of epithelia found, it is always well to give 
equal weight to the clinical manifestations. These are outlined, 
as are the methods for eliciting them, in Chapter VII., on the 
Complications of Gonorrhoea. 

For convenient reference, and until a better arrangement is 
offered, I submit the following description of urethral dis- 
charges, which may be : continuous ; in the mornings only ; in- 
termittent during the day ; intermittent with several days', weeks' 
or months' interval (recurrent gonorrhoea) ; mixed with the last 
portion of urine, or immediately after urination (gonorrhceic 
and other prostatorrhcea) . 

In regard to color and consistence, it may be: watery, al- 
buminoid, rice-water, grayish, thin white, thick white, thin yel- 
low, thick yellow, thick greenish-yellow, thick bloody. 

These discharges may be mixed, as for instance the grayish 
discharge may be mottled with spots of white, yellow, or green, 
or it may be streaked with these colors. 

I may be permitted to emphasize that this classification of 
the discharge of chronic gonorrhoea is offered solely for con- 
venience of recording. 



CHRONIC GONORRHOEA. 131 

A form of discharge characteristic of prostatic involvement, 
and not mentioned above, has a tendency to be drawn out in 
long elastic filaments when taken between the fingers or when 
removed from the urethra with an instrument. When placed 
on a cover-glass it curls up into one or more glutinous heaps. 
When one endeavors to spread these heaps, they drag after the 
instrument with great tenacity. They are difficult to crush be- 
tween cover-glasses, and require considerable rubbing to spread 
them with sufficient thinness into a " smear preparation " (Stern- 
berg) for microscopical examination. Moreover, they require 
much more time for the air-drying than is usually necessary for 
flame fixation prior to staining. The microscope shows them 
to contain many prostatic epithelia and prostatic bodies, in 
addition to the other elements that characterize the special kind 
of infection. 

Discharges Simulating Spermatorrhea.— Guy on and Jamin 
were the first to point out this symptom of chronic posterior 
gonorrhoea, which Guiard J compares to " little ejaculations " 
(petites ejaculations). It is the sudden, intermittent appearance 
of a large drop at the meatus. After the drop has passed to the 
linen, no more discharge can be expressed from the urethra, 
unless by persistent " milking " some normal secretion is pro- 
duced from the pendulous portion. If the patient is not in- 
formed on the subject, he is likely to consider these discharges, 
occurring at irregular intervals, indications of spermatorrhoea 
or of urinary incontinence. 

The stains on the linen produced by these discharges differ 
markedly from those made by anterior gonorrhoea. The occa- 
sional sudden stains are fewer in number and much larger than 
those of chronic anterior gonorrhoea. Both kinds of spots may 
appear together. Those ejected from the posterior urethra at 
irregular intervals generally have yellowish- white centres, with 
clearer and starch-like peripheries, when they have dried on the 
linen. 

Ordinarily the emission of these drops is not accompanied 
by any sensation; their presence is then not noted except by 
the moisture at the meatus or on the shirt, which the patients 
occasionally feel. In some very rare cases the emission of this 

Guiard: Op. cit, p. 161. 



132 THE IRRIGATION TREATMENT OF GONORRHOEA. 

drop is associated with a very brief, somewhat pleasurable sen- 
sation along the urethra, suggesting that produced by the ejacu- 
lation of semen. 

Guyon emphasizes that the compressor will not yield to 
pressure from within until a sufficient degree thereof is exercised, 
and then urethroprostatic discharge is prevented from flowing 
into the bladder by the sphincter vesicae. The discharge so re- 
tained, distending the posterior urethra, evokes reflex contrac- 
tions of the ejaculatory muscles. This view is opposed by 
many authors, but Guiard's 1 observations fully support it. 

While this seems the most rational explanation of this 
symptom, it cannot, however, be compared to the emptying of 
the posterior urethra in ejaculation of semen. During this act 
the posterior urethra is suddenly filled with semen, and while 
the ejaculatory muscles are stimulated to spasm thereby, the 
compressor in this spasm ordinarily yields intermittently, in 
concordance with their contractions. As opposed to the normal 
ejaculations the "little ejaculations," as Guiard designates them, 
appear to premise an extraordinary development of tonicity of 
the sphincter vesicae, preventing the urethroprostatic accumula- 
tion from entering the bladder, which ordinarily is the point of 
least resistance. This extraordinary condition may explain 
the rarity of the symptom under discussion. 

The extrusion of these drops from the posterior urethra 
certainly proves that a posterior gonorrhoea can persist after 
the anterior clap has subsided. It is undoubtedly important 
whenever they are present that their origin be ascertained. In 
this, aside of their macroscopic characteristics mentioned before, 
the microscope will give the final decision concerning their, 
source, whether they proceed from anterior gonorrhoea, pos- 
terior gonorrhoea, seminal emissions, or the " after-dribbling " of 
urine. 

Excessive Moistuee. — In many cases, long after a gonor- 
rhoea is cured, a watery or slightly gelatinoid excess is visible 
on opening the meatus, or can be stripped or milked from the 
urethra. If repeated microscopical examinations of this excess 
of normal moisture proves it to contain only mucus and normal 
epithelium, and if no other symptom of disease presents, it 

1 Guiard: La Blennorrhagie chez Thomme, p. 266, Rueff, Paris, 1894. 



CHRONIC GONORRHCEA. 133 

would be exceedingly unwise to subject the patient to any local 
treatment, no matter how persistently he may implore it. 

The excessive moisture, unaccompanied by other manifesta- 
tions of disease, may be due to a slight catarrhal condition or 
to constitutional depression. The latter is often caused by the 
neurotic state that so frequently is associated with and follows 
gonorrhoea. 

Some patients acquire remarkable dexterity in expressing 
moisture from a perfectly healthy urethra at all times. In do- 
ing so, they keep the channel in an irritated condition, which 
ceases as soon as their thoughts can be diverted from continual 
concentration upon their genitalia. 

If careful examination positively reveals complete absence of 
any local ailment, constitutional remedies will be required. 
Among these, the mixture of tr. cantharid. and iron, recom- 
mended many years ago by that eminent teacher Otis, will be 
found effective in the majority of cases. 

With a view to facilitating the study of excess of moisture, 
its characters are here offered, preliminary to a better arrange- 
ment which doubtless will be made later. 

In volume, the excess may be: expressible with difficulty, 
i.e., slight in quantity; easily expressible, i.e., in quantity not 
sufficient to form a drop, but enough to be visible as an excess 
when the meatus is opened. 

In color, the excess may be: thin watery; thick watery; 
albuminoid, like raw albumen; gelatinoid; grayish; thin white 
(like milk and water) ; thick white, like cream ; rice-water ; yel- 
lowish-white ; yellow; watery, white or yellow spotted or 
streaked; mixtures of any one or more of the above. 

I repeat that this classification has no other purpose than 
ease of description. 

Excessive Sexual Desire. — While the prostate or seminal 
vesicles or both are in a deteriorated condition from chronic 
gonorrhoea, or while the urethra still suffers from the disease 
or its effects, some patients may be annoyed with what they 
call a " teasing " or " nagging " impulse to indulge in sexual in- 
tercourse. This may occur without provocation, or in the pres- 
ence of women who in no wise evoke sensuality, as in a public 
vehicle. Perhaps it may be well to call this symptom " genesic 
hyperesthesia," in order to concisely describe it. An extreme 



134 THE IRRIGATION TREATMENT OF GONORRHOEA. 

case thereof manifested the following conditions : While at col- 
lege, the patient, then aged twenty, contracted gonorrhoea, of 
which he was apparently cured. At twenty-eight he married, 
and became the father of three healthy children during five 
years. His wife was not infected by him. From the time of 
his only gonorrhoea, he was obliged to undergo continual mental 
struggles to master the sexual impulse. His business required 
much dictation to stenographers. In selecting these employees, 
he gave preference to those least likely to suggest lascivious 
thoughts. Imagining that the presence of any woman under 
propitious surroundings aggravated his condition, he eventually 
employed only men, but soon found that the sexual obsession 
was ever present, detracting materially from the mental concen- 
tration his business demanded. A long vacation from his work, 
and devotion to athletic exercise, brought no relief. He finally 
had recourse to bromides with but temporary relief, and the re- 
sult that he became a bromide-habitue. When he was thirty- 
five years old, he was brought for consultation. The urethra 
showed a slight, hard infiltration close behind the posterior 
boundary of the fossa; the prostate was somewhat enlarged. 
Under dilatations of the urethra and prostatic massage for 
about six months, the conditions materially improved. When 
the genesic hypersesthesia had subsided so far that it but rarely 
troubled him, and then only for a few moments, he unfortunately 
was misled into drinking too much champagne at a dinner. The 
next day the condition returned in an aggravated form ; he re- 
verted to large doses of potassium bromide and passed from 
observation for three months. He then wrote that he could not 
summon the courage to discontinue the bromide, which he knew 
would be required of him if he resumed treatment. 

The majority of cases do not, however, terminate in so un- 
happy a manner, but yield to the treatment elsewhere discussed. 

GONORRHOEAS THAT ARE CHRONIC FROM THE INCEPTION. — In 

some cases the manifestations of gonorrhoea are so slight, and 
their progress is so insidious, that they appear to have been 
chronic from the very beginning. These Guiard ' calls urethrites 
chroniques d'emblee. The only symptom may be so slight an 
oozing from the meatus as barely to attract attention. The ap- 

1 Guiard : Les Urethrites chroniques chez l'homme, Rueff, Paris, 1898. 



CHRONIC GONORRHCEA. 135 

parent insignificance of this discharge has no relation to the 
relative number of gonococci it may contain, nor is the patient 
any the less exempt from complications and sequelae of gonor- 
rhoea than if it manifested itself in the hyperacute form. 

I have not observed a case, however, in which a patient's first 
gonorrhoea began with this sole symptom of chronicity. This 
may explain the fact that the gonorrhoeas apparently beginning as 
a chronic disease are more tenacious and resistant to treatment. 

"When the patient denies previous attacks, it may be accepted 
that his memory may be fallacious in this regard. Therefore it 
will be well to explore the urethra and adnexa as soon as pos- 
sible for residua of previous trouble. These must then be 
promptly and thoroughly treated, however slight they may ap- 
pear to be. 

Itching or tickling is one of the most annoying and often 
one of the most persistent symptoms of chronic gonorrhoea. 
When a focus or several foci of inflammation or infiltration can 
be discovered by the urethroscope, the condition can be relieved 
by direct applications of silver nitrate or cupric sulphate. When 
itching or tickling oscillates with varying intensity between spots 
in the anterior and posterior urethra, it may be due : (1) To both 
these regions having diseased foci ; then temporary greater irrita- 
tion in a focus or foci in the anterior or posterior urethra may 
obscure that of the less disturbed region; (2) involvement of the 
seminal vesicles, prostate, or Cowper's glands, from which the 
irritation is reflected forward. In the latter case urethroscopy 
may show a perfectly normal channel; (3) fissure of the anus, 
hemorrhoids, or rectal disturbances. 

When tickling or itching besets the posterior urethra, it is 
often referred to the rectum or anus. Such cases are frequently 
treated for a presumed rectal disease and even operated, natur- 
ally without result. On the other hand, a fissure of the rectum, 
especially when near the raphe, may cause urethral tickling or 
itching. Urethral treatment must then necessarily be fruitless. 

It is necessary, therefore, most searchingly to explore the 
urethra, its adnexa, the anus, and rectum when itching or tick- 
ling in the urethra presents. This sj^mptom is so harassing 
that the local disturbance seriously affects the patient; if long 
continued, it so influences his general condition as to unfit him 
for his vocation. 



136 THE IRRIGATION TREATMENT OF GONORRHOEA. 

When the cause is in th eurethra, it often is so minute that 
its location is difficult, even by the most careful urethroscopy. 
Then if all other causes can be excluded, dilatations and irriga- 
tions fortunately relieve the condition. 

Meatus, Agglutination of. — In some cases the only mani- 
festation of chronic gonorrhoea is a cohesion of the lips of the 
meatus. More frequently still the lips are agglutinated, requir- 
ing a little force to separate them. When the urethral secretion 
is a trifle greater than necessary to produce cohesion or aggluti- 
nation, a little transparent pellicle or even a brownish crust may 
form from the secretion as it dries between and upon the lips of 
the meatus. This crust must not be confounded with the one 
found upon the meatus of uncleanly persons. 

If the incrustation persists, it may make the beginning of 
urination, especially that of the first morning bladder evacua- 
tion, quite painful. The urinary stream tears the crust from 
the meatus and carries epithelium with it. 

Agglutination and incrustation can be avoided in all cases 
by keeping the meatus covered with absorbent cotton soaked in 
bichloride 1 : 10,000 to 1 : 6,000, or boric acid four per cent. The 
cotton so prepared is applied after each urination as described 
under the head of Anterior Irrigations, in Chapter III. 

The avoidance of this symptom, however, by no means im- 
plies its cure. A diagnosis is as necessary here as elsewhere. 
To ascertain its character, a small quantity of the substance 
that agglutinates the meatus is taken with a sterilized (flamed 
and cooled) platinum loop and placed upon a cover-glass. If 
the substance is so dry and hard that it cannot be spread very 
thinly upon the glass, a drop of distilled water added to it will 
quickly soften it, so that it can be spread, dried, flamed, stained, 
and examined in the usual manner (see Chapter XIV., Proofs 
of Cure of Gonorrhoea) . 

The microscopical examination of a specimen so prepared will 
show, in simple urethrorrhoea, epithelium, mucus, and perhaps an 
occasional leucocyte; in chronic gonorrhoea, all the above, de- 
formed or thinned epithelia, or normal epithelia, pus cells, gon- 
ococci, and perhaps other bacteria ; in stricture, when it causes 
the persistence of a gonorrhoea, all the above, and epithelia with 
loss of granulation of the epithelial nuclei or epithelia entirely 
without nuclei; in uncleanliness, mucus, epithelium from the 



CHRONIC GONORRHCEA. 137 

meatus, pus, dirt, and all kinds of bacteria; in consequence of 
erections, mucus, epithelia from several parts of the urethra, 
and spermatozoa. 

Morning Drop. — This term, like its French congener goutte 
militaire, is unfortunately used by many authors as a synonym 
for chronic gonorrhoea. In reality it is only a symptom, and by 
no means a constant one, of chronic gonorrhoeal inflammation. 
When, in this disease, the discharge is continuous, there can be 
no drop that appears at the meatus, in the morning or after 
more or less prolonged intervals between urination; nor is a 
morning drop ordinarily found when the only symptom of 
chronic gonorrhoea is a stain on the linen. 

The persistent presence of this drop after a night during 
which the patient has not urinated, by no means implies that 
the drop contains gonococci. On the other hand, the absence 
of gonococci from the drop does not prove that the patient is 
free from these bacteria. Therefore the appearance of this 
symptom, which may vary from a clear, colorless, to a gelati- 
noid, gray, mottled, white or yellow drop, demands not only 
microscopical examination, but also a thorough exploration of 
the entire urethra and its adnexa. 

If the patient with no other symptom of disease than the 
morning drop cannot come to his physician's office before uri- 
nating, he should be instructed in the proper manner of taking 
the specimen on a cover-glass. This he then brings with him 
for examination. 

Numerous observations of cases in which the morning drop 
free from gonococci was the only symptom of urethral dis- 
ease, have led me to the opinion that its presence is due to the 
effect of gonococci held in some part of the lower urinary ap- 
paratus. The most painstaking and exhaustive examination may 
not reveal the focus of inflammation nor the site where the 
bacteria are residually held. To establish the presence or ab- 
sence of gonococci it will be well, in such a case, to irrigate the 
urethra with silver nitrate 1 : 1,000 or 1 : 500, or mercuric bichlo- 
ride 1:10,000. The discharge produced thereby can then be 
examined for gonococci. But whether they are or are not pres- 
ent, there will be no use in attempting to conquer the morning 
drop with any of the astringent injections of which so many are 
recommended. Even in the absence of any special focus of dis- 



138 THE IRRIGATION TREATMENT OF GONORRHOEA. 

ease, the case must be treated by internal massage of the ure- 
thra, as directed when describing the treatment of chronic gon- 
orrhoea by dilatations and irrigations. 

Painful Ejaculations. — In those not due to the ejaculatory 
spasm drawing upon nerve terminals compressed in infiltrations 
of the anterior urethra, the pain may be due to irritation of the 
chronically inflamed posterior urethra, just as urine, the normal 
stimulant to vesical contraction, gives pain in cystitis, and as 
light, the normal visual stimulant, gives pain in iritis. These 
painful ejaculations, however, are by no means essentially . of 
gonorrhceal origin. In character they may be lancinating, 
burning, extending from the meatus to the rectum, or radiating 
to the testicles and lasting some time after coitus, which may 
be followed by scalding on urination. They are most frequent 
in excesses, such as are likely to be committed by middle-aged 
men in sexual relations with very young women. A most 
aggravated case in which painful ejaculation was the exclusive 
symptom of chronic anterior and posterior gonorrhoea, was that 
of an otherwise normal man, who screamed at the moment of 
ejaculation and fainted before entire conclusion of the act. 
Usually the patients with chronic anterior urethritis complain 
of no pain during ejaculation, or only a slight burning. When 
the pain is sharp, lancinating, stabbing, and extends to the region 
of the anus or rectum, chronic posterior urethritis is prob- 
ably associated with disturbance of the anterior urethra, with 
or without involvement of the seminal vesicles or prostate, or 
both. 

Painful Eeections. — These are comparatively rare when ac- 
companied by sufficient genesic impulse to overshadow the pain. 
But there are cases in which erections without sexual desire are 
provoked by the presence of chronic localized inflammation; 
they then stretch the tense areas or draw upon them, producing 
exquisite pain, while increasing the inflammation. Many a man 
has mere mechanical erections from an overfilled bladder. 
When the urethra harbors a chronic gonorrhea, the erections 
are, as a rule, more or less painful. They subside, however, 
as soon as the bladder is emptied. 

Painful ubination may be frequently evoked in chronic 
gonorrhoea by abnormally irritating urine, as in oxaluria, from 
errors of diet, alcohol, coitus, or overexertion. The irritation 



CHRONIC GONORRHCEA. 139 

produced may cause reawakening of the dormant inflammation 
and with it recrudescence or increase of the discharge. 

Painful urination in chronic gonorrhoea may also be caused 
by agglutination or incrustation of the meatus, produced by a 
small quantity of discharge drying upon or between the lips. 
When sealing of the meatus is very firm, the first urine forced 
from the bladder may distend the urethra most painfully, until 
the incrustation is torn off by the stream. This tearing away 
of the crust is necessarily also painful. "With repetition of the 
act it rends epithelium from the meatus, leaving the lips 
denuded, and increasing the painfulness through the heavier 
incrustation and greater denudation that follow. Decided 
ulceration of the entire meatus can result, if the condition is 
neglected. 

When alcohol or coitus or both have provoked the irritation, 
they must naturally be forbidden; when oxaluria is the cause, 
the diet must be regulated ; in all cases, the patient should be 
ordered to drink large quantities, three or four quarts, of boiled 
water daily to dilute the urine. 

Incrustation of the meatus can be entirely and easily pre- 
vented by causing the patient to keep the meatus continually 
wet with cotton soaked in bichloride or boric-acid solution as 
directed where irrigations are described. When the incrustations 
have formed, pain on urination can be avoided by soaking the 
penis in hot bichloride or boric solution until the crusts are 
softened and can be easily removed. 

Post-Coital Seminal Dkibbllng. — In some cases, in which 
coitus is normal, it is followed by more or less copious dribbling 
of semen from a but partially evacuated posterior urethra. 
This symptom is likely to occur as an independent manifesta- 
tion of urethritis ex libidine. When sexual excesses take place 
during chronic urethritis, they are the more likely to provoke 
the same condition. 

Pkematuke ejaculations frequently overshadow the chronic 
gonorrhoea that causes them, and often indeed are the only 
symptom of the disease. The local symptom may be merely 
too brief intercourse before the ejaculation. A more marked 
form is that in which the emission occurs before intromission, 
with subsidence of the erection as the penis touches the external 
female genitalia. In still more aggravated cases, accidentally 



1-iO THE IRRIGATION TREATMENT OF GONORRHOEA. 

brushing against female garments suffices to provoke the emis- 
sion, while the penis obtains but momentary turgescence, which 
may be so evanescent as to pass unobserved. 

In addition, these patients are usually depressed by fear of 
consumption from the frequent seminal losses, the dread of the 
permanent destruction of their sexual powers, and the fear of 
insanity, which they have cultivated mainly from charlatans' 
advertisements. The despair of these patients is not often over- 
come by the physician's assurances. They regain hope only 
when they observe the beginning of relief from mechanical treat- 
ment. "While this is pursued, the closest attention must be given 
to the accessory treatment mentioned in Chapter VI. 

Simulated Anterior Gonorrhoea. — In some cases the com- 
pressor allows the secretion behind it continually to leak into 
the anterior urethra, giving the appearances of anterior ure- 
thritis. The first urine then coming from the bladder may 
wash out the entire urethra and thus be rendered turbid ; the 
urine following, if it detaches no secretions, may be clear. But 
the last ounce of urine, forcibly ejected by the concluding efforts, 
may be rendered as turbid as the first, or more so, by the de- 
trusor's compression of the diseased organs. If such a patient's 
anterior urethra is gently irrigated and then examined with the 
urethroscope, it will prove to be perfectly healthy. Therefore 
when a case of apparently chronic anterior urethritis does not 
yield to irrigations, the cause may be found in the posterior 
urethra. 

In an extreme case of such a condition, the urethroscope 
found the compressor bulging forward. Slight pressure upon 
it with the distal end of the tube caused it to extrude enough 
secretion to nearly fill one fifth of the tube (30 F.). 

Stains on Linen. — Numerous patients present stains on the 
garments as the only evidence of chronic gonorrhoea. When this 
is the case, in most instances, all endeavors to strip a discharge 
from the urethra either fail, or bring to the meatus, but not ex- 
pressible from it, only a slight excess of transparent moisture. 

Almost invariably these stains on the garments produce more 
mental distress than the discharge did when it was copious, or 
the morning drop when it persisted. 

A patient whose garments become the seat of such stains 
uses every possible means to impress the physician with their 



CHRONIC GONORRHOEA. 141 

importance as evidence of grave disease. One patient, a not at 
all ignorant practitioner, whom I had treated for chronic gonor- 
rhoea, on returning from a visit at midnight, found several spots 
on his shirt flap when he undressed. He awoke me an hour 
later, and to prove that he was not cured produced the shirt, 
with assurance that he intended to commit suicide in my office. 
The color, shape, and appearance of the stains were utterly at 
variance with those that come from urethral disease. My pa- 
tient was not convinced, however, until a microscopical examina- 
tion, made at once, proved a complete absence of bacteria in the 
stains, which, however, contained an exceedingly large number of 
well-formed spermatozoa. He subsequently married the lady 
with whom he had spent the evening; her exceedingly good 
health and frequent pregnancies finally dispelled the doctor's 
apprehensions. 

Some patients bring a formidable laundry bundle to show 
the harassing spots. One wore a shirt an entire week, during 
which he examined it hourly while awake ; whenever he found a 
stain, he encircled it with indelible pencil and in the circle marked 
the date and hour of its discovery. Other patients cut the 
stained portions from the shirt flap and attach labels thereto, 
on which they write the same information. Impatience or 
derision will not relieve the sufferer's mental distress; reassur- 
ances regarding eventual cure are equally fruitless. The pa- 
tients will not obtain mental tranquillity until they cease to 
find the stains. 

When the stains are due to an excess of urethral secretion 
they probably are expelled whenever the secretion has accumu- 
lated in sufficient quantity to evoke slight, unperceived urethral 
contractions. The excess of urethral secretion may be due to 
slight post-gonorrhceal urethrorrhcea, to infiltration of the mu- 
cosa or of glands, or to stricture. 

The gross clinical differences between the stains on the gar- 
ments may be roughly tabulated as follows : 

Stains from urethral Stains from drops of urine Seminal stains : 
discharge: (as in "after-dribbling," 

from enlarged prostate, or 
stricture) : 
Circular or ovoid. Irregularly shaped ; diffuse. Shred-shaped or band- 

like. 



142 THE IRRIGATION TREATMENT OF GONORRHOEA. 

Small, with sharply de- Large, with undefined edges. Elevated edges. 

fined edges. 

Color same throughout. Centre darker than periph- Varying thickness gives 

ery. deeper color in spots. 

As Diday has shown, the stains from urethral discharges, 
very soon after they escape, assume another color than that 
which they had when leaving the meatus. In the little table be- 
low I have added my observations to those of Diday : 

A colorless discharge produces a starch-like stain. 



An opaline 


a 


a 


" grayish " 


A white 


u 


a 


" yellow " 


A yellow 


n 


n 


" green " 


A green 


n 


a 


" reddish-brown " 


A red 


u 


u 


" mottled dark-brown stain 



Whatever the origin of the stain, microscopical examination is 
necessary, not only for the patient's mental peace, but for diag- 
nostic purposes as well. The stained spot is moistened with a 
drop of distilled water and rubbed upon a cover-glass. The 
stain so transferred is air-dried, flamed, colored, and mounted 
in the usual manner. 

Even the most minute stains may contain gonococci ; there- 
fore thej r should not be lightly considered. 

The treatment of the condition producing stains on the linen 
must be directed to its cause. The stains themselves, however, 
can be prevented from soiling the linen by keeping the glans 
continually covered with cotton, as directed under anterior 
irrigations. 

Urethroscopic Findings. — The conditions of the urethra 
that sustain chronic gonorrhoea are sketched in the Outlines of 
Urethroscopy, Chapter XIII. 

The urine in chronic gonorrhcea is made the subject of 
exhaustive discussion iD very many large scientific volumes. 
Manifestly, then, no more can be attempted here than very 
rough outlines of the coarser manifestations that are accessible 
to the beginner in practice and available for rapid office work 
in large practice. The latter, however, cannot be complete or 
satisfactory without at least one assistant continually devoted 
to microscopical research. 

The urine used for examination should be passed in the 
physician's office. For convenience, tubes should be kept in 



CHRONIC GONORRHCEA. 143 

quantity as mentioned elsewhere (page 25). Previous to pass- 
ing the urine, the patient's prepuce, glans, and meatus should 
be cleansed with absorbent cotton soaked in boric acid, so that 
the urine first passed does not carry into the tube the secretion 
of balanitis or the diversity of foreign bodies that are some- 
times found about the glans. Among these Professor Guy on 1 
enumerates mineral dust, coal, wool, silk, linen, hemp, cotton 
threads, bits of hair, feathers, grains of starch, etc. Some of 
these, by their presence, may prove decidedly misleading in 
macroscopical and microscopical examination of the urine. 

The presence of some of these objects, as visible to the un- 
aided eye as are the " floaters " mentioned on page 67, become of 
deep concern to a patient, who, like the majority, observes that 
at each visit the physician carefully notes them. When they 
do not proceed from the urethra, they are easily eliminated by 
the preliminary cleansing mentioned above. 

Malodorous Urine. — This is frequently the first symptom 
which patients observe. It sometimes has a fishy odor in 
chronic posterior urethritis and in tumors of the bladder; an 
excessively aromatic odor after taking balsams (e.g., santal oil); 
a violet-like odor — almost a perfume — after taking turpentine 
preparations, etc. 

Turbid Urine. — If the first urine is turbid it is generally re- 
garded as evidence of anterior urethritis. This, however, is 
open to error, as mentioned in connection with a consideration 
of simulated anterior gonorrhoea. If washing out the anterior 
urethra produces only clear wash-water and the first urine then 
passed is turbid, disease of the posterior urethra is fairly well 
established. If all the urine passed is turbid, it may be due to 
an inflammatory disease of any part of the urinary tract, except 
the anterior urethra, whose pus is generally washed away with 
the first 150 cgm. of urine. 

Donne s Test. — If the turbidity is caused by pus, the addition 
of a saturated solution of caustic potash and then twirling the 
tube, will soon provoke that ropy separation which Donne, who 
devised the test, called "snotty." This forcible term (rotzig) 
does not seem to have yet found a more elegant and equally de- 
scriptive English equivalent. 

^uyon: Maladies des Voies urinaires, vol. i., p. 293, Bailliere, Paris, 
1894. 



144 THE IRRIGATION TREATMENT OF GONORRHOEA. 

If bacteruria causes the turbidity, caustic potash will not sepa- 
rate the clear urine, as above described. 

Phosphaturia can show the urine just as turbid as in either 
of the preceding conditions. A little nitric, hydrochloric, or 
acetic acid will, especially after boiling the urine, clear it with 
the formation of bubbles, causing it to resemble champagne. 
This excess of phosphates may accompany the act of digestion, 
especially in dyspeptics ; it may follow mental exertion, anger, 
fright, or apprehension; it is almost always present in prostatic 
enlargement. 

Perfectly clear and brilliant urine by no means proves absence 
of disease. Centrifuging the specimen may reveal slight but 
positive evidence that some part of the urinary apparatus is 
affected. 

Shreds, fakes, f laments, granules in the urine are the symp- 
toms which bring patients to us long after other manifestations 
of disease have passed. Roughly these substances found in 
clear urine or in urine not so turbid as to conceal them, become 
smaller with approaching restoration to health. With Guyon 
("Maladies des Voies Urinaries ") and Guiard ("Les Urethrites 
Chroniques ") , I deem the following general classification of 
these substances carried in the urine the most convenient for 
ordinary practical purposes : 



Purulent Filaments. Muco-Purulent Filaments. Mucous Filaments. 

Short. Very much longer. Uniformly transparent. 

Multiple. Less numerous, often have 

ends rolled into a ball, 
or are serpentine. 
'Opaque. Yellowish. Not homogeneous, but No opaque spots, 
often consist of thicker 
spots, held together by a 
more transparent sub- 
stance. 
Fall rapidly to bottom ; Sink slowly and remain Light; remain in the up- 
dissolve readily and coherent a long time. per part or float on sur- 
increase turbidity. By twirling the tube face of the urine, 

they can be made to rise 
from bottom. 
Easily removable from More difficult to "fish " as Still more difficult to fish, 
the urine with plati- proportion of pus di- 
num loop. minishes. 



TREATMENT OF CHRONIC GONORRHOEA. 145 

Purulent Filaments. Muco-Purulent Filaments. Mucous Filaments. 

Easily spread upon Tendency to roll into a Tendency to roll into a 
cover-glass ; no ten- thick slippery heap or clear, thick mass on 
dency to curl. serpentine mass upon cover -glass, where it 

cover-glass. dries very slowly and 

then is barely recog- 
nizable. 
Microscopically: Large Microscopically: Leuco- Microscopically: Never 
masses of leucocytes, cytes, often with equal exclusively mucus ; al- 
few epithelial cells, quantity of altered epi- ways have some epithe- 
no mucus. thelial cells, englobed in lial cells, often also a 

a substratum of mucus. few leucocytes. 

The omission of bacteria from the microscopical findings in 
the above table is intentional. They require separate extensive 
study. It must not, however, be forgotten that the heaviest, 
coarsest shreds may be free from gonococci, while the finest of 
short filaments may envelop an abundance of them. 

The other salient symptoms of chronic gonorrhoea are men- 
tioned under the Complications of Gonorrhoea, on page 38. 



IX. TREATMENT OF CHRONIC GONORRHOEA. 1 

Consistent with the character of this little book, theoretical 
considerations will here be entered into only so far as is neces- 
sary to outline the principles upon which treatment is based. 
For the same reason, space cannot be given to even mention of 
the many authors' names who have worked and are working so 
efficiently for the clearer comprehension of chronic gonorrhoea. 
Naturally no thought can be devoted to those who hopelessly, 
from preconceived notions or from lack of energy and persist- 
ence, deem chronic gonorrhoea incurable. 

It seems in place here clearly to establish my position in 
regard to what is called by very many practitioners the " Valen- 
tine method." The success obtained by those who followed my 



1 This and the preceding chapter are somewhat elaborated, in accord with 
the results of two years' increased study and experience, from my article 
on "Chronic Gonorrhoea" published in the Clinical Recorder for January, 
1898. 

10 



146 THE IRRIGATION TREATMENT OF GONORRHOEA. 

writings on the subject makes this designation doubly flatter- 
ing to me. But those who employ the term, even for mere con- 
venience, do an injustice to others, principally Oberlaender of 
Dresden and Janet of .Paris. To Oberlaender belongs all credit 
for initiating and systematizing the use of dilators ; to Janet is 
due all credit for methodizing and popularizing irrigations in 
the profession. The study of and experience with both meth- 
ods led me to simplify and combine them. Since early in 1895 
I began to teach the combination, but always emphasized the 
fact that it is based upon combination and a series of modifi- 
cations of the methods advocated by the gentlemen whose names 
are mentioned above. 

For practical purposes it is convenient to detail the treat- 
ment of chronic urethritis, of which less than ten per cent, are 
of other than gonorrhceal origin, in describing the instruments 
employed. The finer pathological considerations upon which 
the treatment is based can be studied in the more extensive 
works on the subject. 

The local treatment to be followed in a given case is pre- 
dicated upon the conditions that present. 

1. If the affection is superficial it will yield to irrigations, 
as described on page 18. Ordinarily one series, requiring 
eight days of such irrigations, will suffice to cure the case. Oc- 
casion ally a repetition of this series of irrigations will be re- 
quired. 

2. If the urethritis causes structural changes of the mucosa, 
or involves the deeper tissues, or has invaded the ducts of the 
crypts, glands and follicles of the channel, dilatations will be 
required for their own effect. The manner in which these dila- 
tations are performed is described on page 160 et seq. 

3. If the urethritis depends upon invasion of the crypts, 
glands and follicles, these will have to be slit, curetted, or de- 
stroyed by electrolysis before the materies morbida they con- 
tain can be liberated. Similar treatment is required when 
diverticula or false passages complicate the case. 

4. If neoplasms are the cause of the urethritis, they must 
be removed in accord with modern surgical principles. 

5. If the urethral adnexa are involved, they must be treated 
as outlined under complications (Chapter VII.). 

The urethroscopist has a decided advantage over the phy- 



TREATMENT OF CHRONIC GONORRHOEA 147 

sician who does not use this instrument, which exposes to sight 
the urethral disturbance. The patient has still greater advan- 
tage, for when the urethroscope is used treatment can at once 
be directed to the conditions found. 

Until the physician has familiarized himself with the ure- 
thral appearances, his methods will necessarily be tentative. 
The diagnosis, then, being by a slow process of exclusion, is 
obtained by successive failures in treatment. 

Superficial Invasions of the Mucosa. — The quantity, color, and 
consistence of the discharge, the presence or absence of specific 
bacteria, do not indicate the depth of the structural invasion. 
The epithelia contained in the discharge and in the urine, how- 
ever, are valuable guides thereto ; but their differentiation pre- 
mises a degree of special microscopical training whose acquisition 
cannot be too highly recommended. The microscopical findings, 
it must be remembered, are subject to great variability, often 
due to extraneous circumstances. Recognizing this, the most 
experienced microscopist will not decide on the absence of gono- 
cocci, in a given case, before making at least ten examinations 
of specimens, each taken at one or more days' interval. 

The presence of many gonococci in a case of chronic ure- 
thritis does not necessarily convey that the disease has made 
deep ingression, or that serious structural changes exist, or 
that the adnexa are involved. Obversely, a specimen containing 
but few gonococci does not bear evidence that the case is a light 
one, or that it will respond readily to treatment. 

Ordinarily a patient, the superfices of whose urethra are the 
site of the disease, may be expected to recover promptly after 
one, or at most two series of irrigations. These failing, the 
physician who has not assured himself of the coudition by 
means of the urethroscope must conclude that deeper tissues 
are invaded, a fact which he could have established weeks be- 
fore, had he examined the urethra. He will then proceed, as he 
would have done at once, to dilatations. 

Structural Changes of the Mucous Superfices, the Deeper Tis- 
sues, or the Gland Ducts. — Despite the marked pathological differ- 
ences between the conditions here placed together, their grouping 
is warranted by the fact that their efficient treatment is almost 
identical. As long as men have written on urethral diseases, 
drugs of all kinds have been proposed for the treatment of 



14:8 THE IRRIGATION TREATMENT OF GONORRHOEA. 

these conditions and the others that maintain urethral dis- 
charges. The absurdity of expecting remedies injected into the 
urethra to cure changes in its structure does not seem to be yet 
quite evident to all. Indeed, even to-day a medical journal 
rarely appears without at least mention of one drug or formula 
advocated to cure chronic gonorrhoea. Occasionally, in con- 
sequence of vigorous advertising by the manufacturer, a drug 
acquires considerable vogue for a while. Soon it sinks into 
merited oblivion, to which it is relegated even by those who 
strenuously urged it. 

Mechanical methods, too, have their advocates, and have had 
them for a long time. Many proved utopian, but most of these 
have the merit of leading to the use of dilators, which for fully 
fifteen years have proven effective in the hands of those who 
conscientiously employ them. 

Regarding the dilatation treatment of chronic urethral dis- 
eases, Oberlaender 1 says: "As to the principle itself, upon 
which instrumental treatment is based, all agree that the pur- 
pose thereof is to stretch or burst infiltrations, be they hard or 
soft, by means of superficial or subcutaneous injury thereof." 
He further says that the end in view can hardly be attained 
with sounds, owing to the very frequent disproportion between 
the calibre of the meatus and the urethra. Moreover, the in- 
sertion of sounds sufficiently large to produce an effect upon 
the diseased areas is often painful ; indeed even after the widest 
possible meatotomy it is frequently infeasible. 

Some of the above facts which Oberlaender mentions, led 
him to work for a number of years with insufficient spring in- 
struments. Accidentally an Otis divulsor then fell into his 
hands ; in the course of time Oberlaender constructed a number 
of modifications thereof, suited for every zone of the urethra. 

While a sense of justice compels unsparing credit to Ober- 
laender for his modifications of the dilators and his systema- 
tization of the treatment of chronic urethritis, and while he 
must be unqualifiedly acknowledged as the founder of the 
modern and rational treatment of this most frequent and erst- 
while obstinate disease, an honest difference of opinion regard- 

1 Oberlaender : "Die chronischen Erkrankungen der mannlichen Harn- 
Tohre." Klinisches Handbuch der Harn- und Sexualorgane, vol. iii., Vogel, 
Leipzig, 1894. 



TREATMENT OF CHRONIC GONORRHOEA. 149 

ing the principle on which it is based may be allowed. Experi- 
ence and careful observation do not seem to make it necessary, 
nor is it at all obvious from his practice and writings, that the 
effect of dilatations is due to the stretchings or bursting of infil- 
trations. Their effect, on the contrary, seems due to the dynamic 
influence which Guyon so graphically attributes to sounds that 
lie loosely in a strictured or infiltrated urethra. It is within 
the experience of every practitioner that a urethra which 
easily admits a No. 1, 2 or 3 E. sound will, if the sound is 
left in situ, allow a No. 5, 6, or larger calibre to pass readily in 
twenty -four hours. After the same interval the patient finds 
that he emits a larger urinary stream, with less need of aid from 
abdominal pressure than before. The presence of the small 
sound lying loosely in the stricture therefore must induce a 
species of "retrograde metamorphosis," if this term may be so 
applied to the changes in the infiltration itself, that permit a 
part of it to be carried off. Inadequate and elementary as this 
explanation is, it is offered as an introductory to the study of 
the "dynamic influence" (Guyon) of instruments in the urethra 
and to the effect of dilators in chronic urethritis, as established 
by Oberlaender. His terms to " stretch and burst infiltrates " 
are thereby materially modified, as are whatever of violence or 
painfulness they may convey. Indeed, he does the same thing 
in urging gentleness in instrumentation and very gradual in- 
crease in dilatations. 

The gentleness necessary in dilatations is practically em- 
phasized when a very narrow canal or urethral hyperesthesia 
prohibits the introduction of a dilator. Either condition must 
then be overcome by the preliminary use of flexible bougies, 
always selecting one that will readily glide through the urethra 
without producing pain. The limit of usefulness of these 
bougies is reached, usually at 18 or 20 F. when an Oberlaender 
dilator can be readily and painlessly inserted. 

The preparatory treatment of the urethra by flexible bougies 
is subject to the same rules that govern the use of dilators. The 
practitioner will do well, however, to recall the precautions 
necessary for aseptic and thorough, albeit painless work with 
these instruments. 

Previous to the introduction of any instrument, every effort 
should be made to prevent carrying with it infection into and 



150 THE IRRIGATION TREATMENT OF GONORRHOEA. 

from one part of the urethra to another. Naturally, in the light 
of our present knowledge, no pretence can be made to rendering 
the urethra aseptic; yet every precaution must be employed 
to reduce the danger of infection. CleansiDg, preliminary to 
urethral instrumentation, is most easily performed by irrigation 
of the channel as described on pages 12 and 18. When, as at a 
distance from the office, no irrigator is at hand, urethral wash- 
ings may be performed with large hand syringes, such as are 
known as the Guy on or Janet syringes. 

Dilators are inserted into the urethra in the same manner as 
are most other instruments. The penis, held erect in the left 
hand, causes the pendulous portion of the urethra to form an ap- 
proximate right angle to the mesian line of the body. The fossa 
navicularis (scaphoid fossa) forms an obtuse angle with the ure- 
thra. Therefore an instrument to easily enter the canal should 
be guided first through the fossa in the direction of its lumen, 
then turned upward, to pass into the urethra. It may meet an 
excessively developed lacuna magna, which may receive the 
point of the instrument, and, if violence is employed, expose the 
patient to the dangers of urethral laceration. This danger is 
the greater the smaller the instrument employed. The lacuna 
magna is situated in the upper urethral wall ; therefore, to avoid 
it, the instrument should here be guided along the floor of the 
caaal. All works on surgery that have been searched on the 
matter of urethral instrumentation, except a paper by Murcell, 1 
urge that the passage of an instrument throughout the anterior 
urethra must be along its roof, where it will meet with few or no 
rugosities. In theory this course seems correct. But the sur- 
geon's concentration being directed to the roof of the urethra, 
he can allow the rugse of its floor to escape the attention of the 
instrument which at the time is prolonging his tactile sense. 
Minute study and extended experience will make plain the great- 
er safety and ease of adopting a diametrically opposite course. 
The smallest damage that can then be done is an interference 
with the easy passage of the instrument. This can be at once 
remedied, and it will be almost automatically done, if the tip of 
the instrument is made to hug the floor of the urethra. Then 

J H. Temple Murcell: "Some Points in the Diagnosis and Treatment of 
Urethral Stricture." Treatment, July 27th, 1899. 



TREATMENT OF CHRONIC GONORRHOEA. 151 

the most minute impediment to its onward course causes the 
surgeon to withdraw the instrument ever so slightly and point 
its tip toward the roof enough to easily override the obstacle. 
In this manner urethrospasm, which would interfere with the 
work, is avoided, as is laceration of the urethra. 

We are also urged to avoid the floor of the bulbous portion 
and the region beyond, as it is the urethra's least supported 
part, and therefore the one most exposed to injury. Again, in 
this regard a difference in opinion and practice from that of our 
justly most honored colleagues in the specialty, may be per- 
mitted. Greater safety to the region lies certainly in seeking 
it, with that exquisite gentleness which must characterize all 
genito-urinary work. Thus, if it be kept in mind that the sinus 
of the bulb may be quite a pouch and this obstacle to the in- 
strument's progress be carefully sought, a slight withdrawal of 
the instrument and raising its point to override the opening of 
the pouch are more likely to lead to success than timorous 
avoidance of the region. When the compressor is passed, how- 
ever, the point of the instrument must hug the roof of the pos- 
terior urethra, which here is the channel's true "surgical wall," 
to avoid contact with the sensitive caput gallinaginis and the 
mouths of the ducts that open in this region. 

All dilators, except those provided with an irrigating device, 
are clothed with a rubber cover before their insertion into the 
urethra. Excellent covers for all the dilators are made accord- 
ing to my directions, by the Miller Kubber Manufacturing 
Company, of Akron, Ohio. These covers differ from those of 
European manufacture essentially in being about one millimetre 
greater in calibre and in being finished with a smooth, instead 
of a ribbed, surface. The greater calibre permits their easier 
adjustment to and removal from the dilators; their smooth sur- 
face makes the insertion of a dilator as painless as the correct 
introduction of a solid instrument with a highly finished, 
nickelled surface. 

Clothing dilators with these new covers is performed by 
grasping the mouth of the cover with the left fingers and drawing 
the cover over the dilator. This can always be done with ease 
if the cover is thoroughly dry. No attempt should be made to 
apply a cover if it retains the slightest moisture from steriliza- 
tion. 



152 THE IRRIGATION TREATMENT OF GONORRHOEA. 

Although the element of expense has no weight in aseptic 
considerations, it is well to remember that the price at which 
these covers are furnished makes it quite an economy to throw 
them away after one use, in preference to devoting the time, 
labor, and cost of materials to their resterilization. 

But, unless the covers are bought in a sterilized condition 
and enclosed in glass tubes, they should be sterilized before 
each use. To this end they must be scrubbed in boiling water 
with soap, each one then wrapped in a sterilized gauze napkin 
and boiled seven minutes in a one-per-cent. carbolic-acid solu- 
tion. They may then be left to dry for use. Easier still is dry 
sterilization in formalin fumes, after scrubbing with soap and 
hot water. After sterilization and drying, if the wet method is 
employed, the covers must be placed in a long shallow glass 
or porcelain tray, closed with a tight-fitting lid of the same ma- 
terial. Beneath and upon each layer of sterilized covers a 
liberal quantity of finely powdered, sterilized talcum is dusted. 
If the gauze napkin is left open at the orifice of the cover, 
enough talcum will enter to keep its inner surface dry and facili- 
tate its gliding upon and from the dilator. 

After a dilator is clothed with its cover, the instrument is 
struck several times upon the gauze napkin that enveloped it. 
The napkin is folded or crumpled in the left hand to receive these 
blows by means of which any talcum adhering to the cover's 
outer surface is removed. 

After clothing the dilator smoothly and assuring himself 
that folds are nowhere formed, the operator violently turns the 
screw at its handle, as if to forcibly burst the cover. When the 
branches of the dilator are so expanded to their fullest extent, 
every part of the cover is carefully examined for minute orifices. 
In new, well-made covers these will not be found. It is mani- 
festly better that, if a cover contains holes or can be burst by 
the dilator, this be learned before it enters the urethra. A de- 
fective cover inserted would permit urethral secretions to enter 
the delicate joints of the dilator, and, what is far more impor- 
tant, endanger the urethral mucosa to being grasped and injured 
by the dilator's branches. 

When the above tests of the cover's good condition are com- 
plete, it is lubricated from its point to half an inch along its 
shaft. The material experience has shown most useful for this 



TREATMENT OF CHRONIC GONORRHOEA. 



153 



purpose is lubrichondrin, made according to Professor Bangs' 
direction. It is composed of the gelatinous substance of chon- 
drus crispus (Irish moss) to which eucalyptus oil 1:1,000 and 
formaldehyde 1:1,500 are added. Lubrichondrin is sold in 
collapsible tubes and in glass-stoppered salt mouths. The 
former can be resterilized by boiling the closed tube in water. 
In using a tube its bottom is compressed to force out the con- 




Fig. 40.— Lubricating the Meatus. 

tents, of which the necessary quantity can be placed directly 
upon the dilator cover. When the bottles are used, about a 
sixth of a drachm of lubrichondrin is poured into a sterilized 
Petri dish, whence it can be readily taken upon the point of the 
dilator. 

Unless the physician is ambidextrous, it will be well for him 
to stand at the right side of the table upon which the patient 
lies. The meatus being cleansed with cotton and bichloride, 
and the urethra washed as directed in this chapter, the penis is 
held as before suggested, and a part of the lubricant smeared 
upon and between the opened lips of the meatus by drawing 
one side of the covered dilator over them. Then the dilator 



154 THE IRRIGATION TREATMENT OF GONORRHOEA. 

may be inserted. In doing this, no force whatever should be 
employed. When a dilator for the anterior urethra is used, it 
is best held as if it were a pen grasped for writing. While fol- 
lowing the suggestions before made, until the posterior bound- 
ary of the fossa navicularis is passed, the right hand exercises 




FIG. 41.— Oberlaender Anterior Dilator. 

a species of restraining force to prevent the weight of the in- 
strument violently plunging it into the urethra. 

The selection of a dilator is necessarily predicated upon the 
location of the disease and the calibre of the urethra. If the 
anterior urethra alone requires treatment and the urethral calibre 
is still small, Oberlaender' s anterior dilator is used. This in- 
strument has a slight curve near its tip, to readily accommodate 
it to the normal curve of the anterior urethra. The tip is rather 
small, permitting its insinuation through a stricture so narrow 
that it will let no instrument beyond 10 F. pass. The smallness 
of the tip should be well kept in mind when using this instru- 
ment ; if the greatest of gentleness is not employed, it may en- 
gage in a mucous fold, a wide open duct mouth, or a previously 
made false passage. The instrument will then not proceed. 
The slightest force employed is likely to produce serious ure- 
thral laceration. When an obstacle of any kind impedes the 
easy progress of the dilator, the instrument must be immedi- 
ately withdrawn and a successive systematic series of other 
directions given its point. With well-developed tactile sense, 
however, the surgeon is enabled by gently touching all parts of 
the obstacle to form a clear mental picture of its character. 
When the point of the instrument has found the correct urethral 
lumen, it will easily, smoothly glide to its destination, unless 
again impeded by further obstacles. These then will have to 
be overcome in the same manner as the first. 

Greater safety from injury to the urethra is obtained by in- 
serting the Oberlaender anterior dilator by a technique similar 
to that employed in introducing dilators for the posterior ure- 
thra, which will be detailed in discussing these instruments. 



TREATMENT OF CHRONIC GONORRHOEA. 



155 



The curve of the Oberlaender anterior dilator being the nearest 
approach to that of the anterior urethra therefore exercises the 
most direct pressure upon its roof and floor without distorting 
the canal. This consideration of the urethral curve is unneces- 
sary when the channel is or has become sufficiently capacious 
to easily admit the Kollmann anterior dilator, which is described 
below. 

The steps of inserting the Oberlaender anterior dilator are 
as follows : 

1. The patient lies on a firm table with his legs extended 
and a sterilized towel placed upon his abdomen covering the 
pubis, another over his testicles and thighs. The penis rests 
upon the latter towel. 

2. After the penis has been cleaned, the glans is taken be- 
tween the left thumb and index finger. 

3. The penis is gently placed in the direction of the right 
thigh, in a line continuing the left Poupart's ligament. 

4. The clothed Oberlaender anterior dilator is then taken as 




Manner of Holding Dilator. 



before described, like a pen, with the face of the dial resting 
upon the interspace between the right thumb and index finger. 

5. The tip of the instrument is inserted into the meatus. 

6. After overcoming the angle at which the fossa stands to 
the urethra, the penis is drawn over the dilator, as a glove is 
drawn over a finger, but far more gently. The tip of the instru- 
ment is so guided along the floor of the urethra until the bulbous 



156 THE IRRIGATION TREATMENT OF GONORRHOEA. 

portion is reached. The surgeon then experiences a sensation 
of reduced resistance at the instrument's point. 

7. Without increasing the pressure, but keeping the tip im- 
mobile, the surgeon carries the penis containing the dilator in 
about a three-quarter circle in the same plane, around and be- 
yond the patient's left side, until the dial of the dilator faces 
the linea alba at its commencement above the pubis. 

8. Keeping the tip within the bulbous portion, the dilator is 
now gently tilted from the floor to the roof of this region, and 




Fig. 43.— Patient in Position During Dilatation. 



the penis with the dilator raised until it stands at right angles 
to the body. 

9. The patient's elbow, either right or left, is rested against 
his side to steady his arm. He is then asked to grasp the 
dilator, where its cover projects from the meatus, and hold it 
in this position. 

10. If the dilatation is to be in prolonged session it will 
materially contribute to the patient's comfort to raise the back 
of the table to about forty-five degrees and elevate its feet. I 
find the tables made by the Allison Company most convenient 
for the purpose, as well as for all other genito-urinary work 
done in the office. 



TREATMENT OF CHRONIC GONORRHOEA. 



157 




Further manipulations with the Oberlaender anterior dilator 
do not differ essentially from those to be described in discuss- 
ing the other dilators. 

Kollmann's four-branched dilator for the anterior urethra is 
intended for use when the urethra's capacity 
is, or when previous dilatations have brought 
it to 21 F. The technique of its employ- 
ment is the simplest of all 
dilators. After the dilator 
is clothed with its cover 
and lubricated, the penis 
is held in erect position 
by the left hand. The di- 
lator is slowly inserted, 
observing the general rules 
before mentioned. The 
dial may be placed in any 
direction, as the instru- 
ment when closed is per- 
fectly round. The one of 
choice will naturally be 
that in which the light 
strikes the dial, so that 
the figures thereon can be 
easily read. 

Oberlaender's Benique- 
curve dilator exercises 
pressure only within the 
posterior urethra. The 
technique of its insertion 
is as follows : 

1. Follow all the steps, 
from 1 to 8 inclusive, laid 
down for the introduction of the Oberlaender 
anterior dilator. 

2. "When the tip of the instrument has been raised to the roof 
of the bulbous portion, guide it gently through the compressor, 
while letting the handle sink between the patient's thighs. 
In this motion, contact of the tip with the delicate and sensitive 
structures at the floor of the posterior urethra is avoided. 




158 



THE IRRIGATION TREATMENT OF GONORRHOEA. 




Undeniably brilliant results are obtained in affections of the 
posterior urethra from the use of this dilator, without disturbing 
the anterior urethra. In the premature ejaculations due to 
irritability of the posterior urethra from 
masturbator's chronic hyperemia, it often 
exercises a decided salutary effect. But it is 
not an instrument that can be recommended 
to any save those whom large experience 
has made familiar with intra-urethral work. 
§ The very great Benique curve, alarming 

2 as it may appear to the patient, allows the 

instrument to lie very easily in the urethra, 

1 without making any traction whatever upon 

3 its normal bend. But this very curve and 
^ its small tip make its introduction safe only 
| in trained hands. 

§ Kollmann's four-branched dilator for the 

^> 

2 bulb and posterior urethra is a much safer 
| instrument to use. It cannot, however, be 
§ employed through an anterior urethra whose 
| capacity is less than 21 F. Its large tip ex- 
's eludes the danger of injury, unless violence 
i is employed. Its Guy on curve, about one- 
§ half of that of the Benique, does not exer- 
g cise any appreciable traction upon the ure- 
§ thra, while its great weight adds to the 
% ease of its introduction. The technique 
o thereof is the same as that laid down for 
£ the Oberlaender posterior dilator. 

Oberlaender's curved dilator for the pos- 
terior and anterior urethra is used when 
both these regions require dilatation. The 
technique of its introduction is identical 
with that directed for the Oberlaender Be- 
nique-eurve dilator. The angle at which it 
is depressed between the thighs governs 
the dilatation that is to be done within the bulbous portion or 
beyond. Dilatation of the anterior urethra is accomplished at 
the same time. 

Kollmann's four-branched Guyon-curve antero-posterior 




TREATMENT OF CHRONIC GONORRHOEA. 



159 



dilator is applicable when both urethras require treatment and 
permit the passage of an instrument over 21 F. The technique 
of its insertion does not differ from that before described for the 
instruments intended for these regions. 





Kollmann, whose ingeniousness seems to have no limit, also 
devised irrigating dilators (Fig. 49 and 50). They are used 
without rubber covers. Surgical cleanliness of these irrigating 
dilators is obtained, according to the author's directions, as 
follows : 



160 THE IRRIGATION TREATMENT OF GONORRHOEA. 

1. Place the dilator into absolute alcohol for an hour before 
use ; then' pass it over a flame, burning off all the alcohol that 
adheres to it. 

2. When the dilator has grown cool, stand it upright in a tall 
vessel and force boric acid through its canals. 

3. Previous to inserting it into the urethra, pass a sound 
and leave it there for a few moments. 

4. Anoint the dilator freely with glycerin before inserting it. 

5. After use, scrub the dilator vigorously with soap and 
water. After having dried it, cleanse with benzin applied by 
means of a tooth-brush, and then with absolute alcohol. 

These dilators, when inserted, have a short rubber tube at- 
tached to one of their nipples and a long one to the other. The 
short tube is connected to a syringe by means of which the 
irrigation fluid is forced through the dilator into the urethra and 
gathered by outflow channels to the long rubber tube, which 
conducts it to a vessel below the table. 

In exceptional cases this immediate combination of dilatation 
and irrigation proves useful. But the instruments, from their 
very construction, require the hands of the specialist for their 
use. 

The technique of dilatations is the same for all dilators, viz. : 

1. After the instrument is in the necessary position, so that 
the region known to be diseased embraces the branches of the 
dilator, it is held motionless long enough to allow the discom- 
fort of its presence to pass off, if such discomfort is experienced 
at all. This varies from a few seconds to half a minute. Dur- 
ing this time the penis is held steadily by the left hand and 
drawn out its full length, while the right hand keeps the dilator 
immovably in its position. 

2. Grasp the penis with the four left fingers and palm, and 
extend the left thumb to the ring at the dilator's handle, thus 
holding both the penis and the dilator immovably together. 

3. With the right thumb, index and middle fingers take the 
large screw-head or disc at the handle of the dilator and very 
gently turn it to the right. Continue this until the first slight 
resistance to its easy progress is felt. 

4. If the patient is not extraordinarily timorous, it will then 
be well to entrust the dilator to him for a few moments. It 
occupies his attention and remeves any apprehension he may 



TREATMENT OF CHRONIC GONORRHOEA. 161 

have of pain that may be produced. At the same time it 
avoids cramping the surgeon's fingers which would interfere with 
further delicate dilatations. The patient may be instructed to 
avoid cramp by holding the dilator with the other hand, when 
the one grows fatigued. 

5. At the first seance leave the dilator at the first point of 
resistance for from three to five minutes, unless an especially 
spongy mucosa, as evidenced by bleeding, urethrospasm, hyper- 
esthesia, or fear of pain, obliges its removal before. 

6. Close the dilator's branches by very slowly turning its 
screw-head to the left. In doing so, watch the dial and turn 
the screw-head no further than to leave it open one-half or one 
number E. to preclude the very remote and most unusual, but 
possible, accident of a collapse of the rubber cover permitting the 
branches, if closed entirely, to grasp the urethral mucosa. 

7. Kemove the Kollmann anterior dilator by drawing the 
penis back with the left hand and at the same time drawing the 
dilator from the urethra with the right. Kemove any one of the 
other dilators by tilting the anterior margin of the instrument 
as if to dip it into the umbilicus ; the penis will then drop be- 
tween the legs, after the urethra has painlessly slid from the 
rubber cover. 

8. After each dilatation, irrigate the region that was invaded : 
i.e., after an anterior dilatation, irrigate the anterior urethra; 
after a posterior dilatation, irrigate the bladder. The solution 
most frequently employed for this purpose is potassium per- 
manganate 1 : 6,000. In some cases this proves quite irritating 
after dilatation; then it may be used at one-half this strength, 
viz., 1 : 12,000 or four-per-cent. boric-acid solution may be sub- 
stituted. When the urethra harbors many other bacteria besides 
gonococci or without them, silver nitrate 1 : 5,000 or 1 : 3,000, or 
stronger if it can be borne, will be found effective. 

Irrigations should never be omitted after dilatations or in- 
deed any urethral instrumentation. Without them, the dis- 
charge is materially increased and often persists several weeks. 
Pain on and even between urinations may become quite severe 
and all the appearances of a new gonorrhoea may set in. The 
cause thereof is evident. If gonococci are squeezed from the 
mouths of ducts or from structural interstices, they may infect 
urethral regions that had returned to the normal state or that 
11 



162 THE IRRIGATION TREATMENT OF GONORRHOEA. 

had remained free from infection. The results of omission of 
irrigations after instrumentation, if they portend nothing further, 
would entail a delay in dilatations until the reawakened acute 
condition has yielded to additional treatment. 

But another greater and more immediate danger attends 
omission of irrigations ; that is, urethral fever (" catheter fever "). 
It will suffice to say here that since making it an inflexible rule 
to irrigate after each instrumentation, not a single case of ure- 
thral fever has resulted. 

Frequently on the morning after a dilatation followed by 
irrigation, the patient will find a slight increase of the discharge. 
If this continues until the second morning, the urethra should 
be again irrigated on that day ; rarely will a third irrigation be 
required. 

The frequency of dilatations, the amount of dilatation and 
its duration at each seance, must necessarily be governed by the 
condition of each case, the toleration of the patient, and the 
results of the preceding dilatations. 

A good average working rule to keep within the limits of 
safety is : (1) Begin with two dilatations weekly ; (2) increase 
each dilatation one-half number F. over the preceding num- 
ber reached; (3) prolong each seance two minutes. The 
longest seance, however, a patient can generally endure is 
forty -five minutes. Therefore when the seances have reached 
this limit, the dilatation desired must be attained within this 
time. 

Variations from the above may become necessary : 

1. When the increase of discharge persists, as it may in 
very rare cases, beyond three days. It must then be controlled 
by irrigations. 

2. When marked improvement in the general and local con- 
dition shows that the intervals between dilatations may be ex- 
tended. Experience has shown that recurrences are most likely 
to result when the intervals between treatments are too sud- 
denly made. Therefore the extension must be gradual. Thus, 
for instance, if a patient was treated on Mondays and Thursdays, 
and it be determined on a Monday to extend the intervals be- 
tween his visits, a risk would be incurred by asking him to omit 
the treatment for a week. Therefore the next appointment is 
made for Friday. If then he is found in continued improve- 



TREATMENT OF CHRONIC GONORRHOEA. 163 

ment, the following visit is set for Wednesday, and each inter- 
val increased by one day in this manner. 

3. When it is found that the usual increase of dilatation by 
one-half F. over the preceding number, or even the preceding 
number itself cannot be reached without producing even slight 
pain, the patient may explain the condition by an intercurrent 
digression into the paths of Yenus or Bacchus or both. With- 
out such an occurrence the preceding dilatation may have pro- 
duced a temporary swelling of the mucosa, which readily sub- 
sides. The physician, when such an impediment presents, 
contents himself by dilating as much as possible, without pro- 
ducing any discomfort. He may confidently reassure the pa- 
tient that the time lost by delay in progress or even in decrease 
of the progress will be regained in a few sessions. 

4. When a spongy mucosa, as shown by blood oozing from 
the meatus, a reawakened hyperesthesia or urethrospasm com- 
mand the removal of the instrument before the time required 
for the day's dilatation, the latter must be abbreviated. 

5. When a dilatation is followed by oozing of blood from 
the meatus, bloody urination, or pain, the subsequent dilatations 
must be increased by but a quarter number at each session. If 
even this slow procedure is still followed by any of or all the dis- 
turbances mentioned, it will be well to substitute flexible bougies 
for the dilator until the use of the bougie no longer produces 
the objectionable symptoms. The bougie selected must be five 
numbers F. less than the last dilatation. Thus if the number 
reached by the dilator was 25, the bougie to take its place 
must be 20, or a size as much smaller as will glide through the 
urethra easily and painlessly. 

While, as a rule, the increase of dilatation at each session of 
one-half number F. is not interrupted, this increase should never 
be obtained by force. Nor should the beginner attempt to ex- 
ceed this, even when no resistance whatever presents thereto. 
Those most experienced in dilatations prefer the slow progress, 
because of the greater safety it assures. 

The best practice is to stop dilating at the number last 
reached or at the first slightest resistance, and then at from three 
to five minutes' intervals to dilate at no more than half numbers, 
or up to slight resistance, until the number desired for the day 
is attained. 



164 THE IRRIGATION TREATMENT OF GONORRHOEA. 

When a patient observes his improvement under dilatations, 
he is likely to urge more rapid advances than above directed. 
Such patients, when not watched, are tempted to surreptitiously 
give the dilator's screw-head a rapid turn. Those most prone 
to thus viciously maltreat their urethras are physicians afflicted 
with chronic gonorrhoea. Until a locking device is invented 
that will prevent such patients endangeriDg their urethras, it will 
be well in their protection to refuse a continuance of treatment, 
unless they pledge themselves not to interfere with the case. 

Bleeding to quite a considerable extent sometimes follows 
dilatations, especially in the beginning of treatment. Such a 
hemorrhage is usually of very short duration; if it threatens 
to become excessive, the penis may be compressed by a bandage 
until it ceases. Obstinate cases may require the pressure of a 
sound within the urethra in addition to the bandage. This 
failing, very cold water passed through a psychrophore will, in 
the majority of instances, arrest the bleeding. In extreme cases, 
such as are cited on page 77 (Complications), the urethra may be 
packed in the manner there described. When bleedings to any 
extent follow dilatations, it will be well to endeavor to control 
erections by the treatment mentioned on page 47 (Chordee), lest 
the erections cause the bleeding to recur at night. 

As mentioned before, one of the results of dilatations is an 
increase of discharge on the morning following treatment, or its 
recurrence if no discharge existed. Oberlaender looks upon 
this as an evidence of the " melting " of infiltrations. However 
this may be interpreted, the discharge in a case that proceeds in 
the ordinary manner is less in quantity, thinner in consistence, 
and lighter in color at each recurrence, until it ceases entirely. 
The products of inflammation that are carried off in the urine 
become smaller and less in quantity. With these manifesta- 
tions the general condition of the patient improves and local as 
well as reflex manifestations of disease fade away. 

The limits of dilatation and irrigation are reached when no 
more evidences of disease exist or can be evoked by the tests 
mentioned in Chapter XIY. (The Proofs of Cure of Gonorrhoea) . 

There are but few conditions in which dilatations are contra- 
indicated. Decrepit persons, those in acute febrile conditions, 
those with large vesical tumors or with genito-urinary tuber- 
culosis, or those in whom a severe posterior urethritis persists 




TREATMENT OF CHRONIC GONORRHOEA. 105 

must not be dilated. The last mentioned must be treated by 
irrigations, or by Guy on' s instillations of silver nitrate, until 
the condition of the posterior urethra ceases to be an impedi- 
ment to dilatations. 

Invasion of the crypts, glands, and follicles was alluded to in 
this chapter under the third class of causes upon which the 
chronicity of a gonorrhoea may depend. In such a case dilata- 
tions and irrigations 
will have no appreci- 
able or lasting effect 
while these recesses 
harbor infectious bac- 

Kollmann's Urethral Gland Syringe. teria. Any attempt 

to treat such cases, 
except locally, by means of the urethroscope, must be 
abjectly hopeless. 

Among the many inventions for which the profession 
is indebted to Kollmann are instruments for treating these 
cases. His urethral gland syringe is the first to be con- 
sidered. By means of this little instrument silver nitrate 
can be injected directly into the invaded glands, as they 
are exposed by the urethroscope. These injections fail- 
ing to effect a cure, the glands can be evacuated by his 
sharp curette. If curettage does not accomplish the de- 
sired end, his electrolytic needle will effectively destroy the 
invaded urethral adnexa. For this purpose, the needle 
is attached to the negative pole of the galvanic battery ; 
the positive electrode is placed firmly upon the thigh. 
The needle is then carefully inserted into the gland as deeply 
as is possible without force ; the current is turned on very slowly. 
At two or three milliamperes, white bubbles will be seen rising 
from the gland about the needle; as the instrument is sunk 
deeper and swept about the gland, these bubbles increase. The 
surgeon will have to estimate the manipulations required to 
entirely destroy a gland. The time necessary varies from five 
to fifteen seconds. The pain of electrolysis is easily borne by 
most patients. An exceptionally sensitive case may require 
cocainization. To minimize the pain the current should not 
be made before the needle is inserted, nor should the needle 
be removed until the current is gradually reduced and finally 



166 THE IRRIGATION TREATMENT OF GONORRHOEA. 

broken. Ordinarily not more than three or four glands can be 
destroyed at one seance ; even if the patient is willing to bear 
the prolonged pain, more such work would be inadvisable, 
owing to the excessive reaction that would thus be produced. 
The greater ease and safety with which the glands can be de- 
stroyed by electrolysis makes this method preferable to the 
intraglandular injection and curettage before described. The 
intensity of the reaction can be very much reduced, and often 




Fig. 52.— Kollmann's Electrolytic Needle for the Destruction of 
Diseased Urethral Glands. 



entirely obviated, if each electrolytic seance is followed by an 
irrigation, as should be every instrumental invasion of the ure- 
thra. 

Neoplasms of the urethra, mentioned in this chapter as the 
fourth class of conditions that maintain a urethritis chronic, 
are not amenable to treatment except by aid of the urethroscope. 
When they take the form of growths upon the urethral surface, 
they must be removed, as directed under Complications (page 
50) . When they are interstitial as well as superficial, they ap- 
pear as dry, gray-looking cicatricial masses. Oberlaender 
recommends splitting these with his urethroscopic knife. The 
necessity of resorting to such incisions has not presented in my 
experience. Successive punctures of such infiltrates with Koll- 
mann's electrolytic needle, each seance followed by an irriga- 
tion, have thus far sufficed to gradually overcome them. The 
objective point is usually best attained by treatment twice each 
week, one seance devoted to electrolysis and the other to dilata- 
tion. 

Invasion of the urethral adnexa, placed in the fifth group of 
causes that maintain the chronicity of gonorrhoea, may present 
as Cowperitis, vesiculitis, or prostatitis, or two or all of these. 
Their treatment is sketched under Digital Palpation of the 
Urethral Adnexa, page 173-. 

Over- Treatment. — This cause for the continuance of a chronic 
urethritis has not been considered in the foregoing groups. 



TREATMENT OF CHRONIC GONORRHOEA. 167 

Yery few of the best-known authors give it more than casual 
mention. Among these Furbringer emphasizes the fact that 
the urine will contain filaments as long as the urethra is dis- 
turbed by instruments. 

If a urethra that had never been infected were subjected to 
persistent instrumentation, even under the strictest aseptic 
precautions, it would sooner or later resent the intrusion, obedi- 
ent to the maxim "ubi irritatio, ibi afftuxus" if not otherwise 
than by irritative urethritis. 

A urethra that was diseased and has recovered is necessarily 
at least as prone to be affected by unnecessary treatment. If 
all the tests advocated in Chapter XIY. (The Proofs of Cure in 
Gonorrhoea) yield a negative result, the physician will be justi- 
fied in discontinuing treatment. But the exigencies of general 
practice, among other reasons, prevent many physicians from 
becoming sufficiently expert urethroscopists, microscopists, and 
chemical analysts of urine for this purpose. The test that then 
might suggest itself, would be to risk discontinuance of treat- 
ment, with intentions to resume it should evidences of disease 
again present. This would be as dangerous to the patient's 
health as it would be to the physician's reputation. I believe 
that I have devised a fairly effective means of covering such cir- 
cumstances ; this means is suggested when discussing the inter- 
vals between dilatations (page 162). Naturally it will apply 
only when, for any reason, the direct and decisive tests of cure 
cannot be made. 

This suggestion is that when marked improvement shows 
itself, the intervals between treatments be prolonged one day 
each. On the third day of the second month after instituting 
such extension, the patient would have been eight days without 
treatment. If he continues to improve during this interval, the 
next one could safely be made twelve days. The improvement 
still continuing, the next interval could be eighteen days. This 
would bring the case to the third day of the third month of in- 
stituting the prolongation of intervals. Thus increasing the 
intervals between treatments by one-half each, after the eight 
days' interval has been reached in the ordinary course, would 
bring the next day of treatment twenty-seven days, or nearly 
a month from the preceding one. 



168 THE IRRIGATION TREATMENT OF GONORRHOEA. 

Then it will be found that : 

If the Urethra is still Diseased : If the Patient has Recovered : 

On the day after treatment the discharge Recrudescence of the discharge may 

may become evident again. This continue, but not as many days as 

may continue several days. it would in a still diseased condi- 
tion. 

The floaters in the urine may increase Floaters appear in the urine that was 

in dimensions and numFer on the hitherto clear. They are, however, 

day or for several days after treat- fine and few. They disappear soon. 

ment ; then they grow less in number 

and smaller in dimensions, but do not 

disappear. 

Toward the end of the interval be- The discharge does not reappear, nor 

tween treatments or before, the dis- does any abnormal moisture pre- 

charge or excess of moisture may re- sent at the meatus ; the floaters do 

appear; the "floaters" in the urine not reappear. 

become more numerous and more 

gross. 

For the sake of emphasis it may be repeated that this means 
of establishing the need of continuance or cessation of treatment 
is exceedingly crude and prolonged, but it is offered to take the 
place of the other correct, scientific method when the latter is 
not available. 

X. " RECURRENT » GONORRHOEA. 

A deliberately intentional misnomer heads this chapter, for 
the purpose of grouping under it the recurrences of apparently 
cured gonorrhoea without new infection. 

A recurrence, with or without an exciting cause, soon or 
many years after a clap has ceased to produce any manifesta- 
tions, is but a symptom of residual gonorrhoea. Until the loca- 
tion of the residual (latent, quiescent) affection is ascertained, 
the disease cannot be cured, nor the patient relieved from its 
dangers. It is this phase of gonorrhoea that has misled some 
good men to deem it an incurable disease. 

Recurrent gonorrhoea certainly offers great menaces to the 
patient and others, mainly because of the fancied security in 
which the former lives. Deeming himself cured, he may marry 
and infect his wife, or, with or without infecting her, the disease 
may recur in him so many years after the first or last attack 
that it had become but a dim shadow of the past. Unless it can 



169 

be made evident that lie reinfected himself, a family disruption, 
because of the presumption of infidelity on part of either hus- 
band or wife, with all its sad consequences, is prone to result. 
This is especially likely to be the case if gonococci are found 
in the wife's genital secretions. 

Few physicians indeed there are, in general practice or in 
the specialty, who have not seen such recurrences of gonorrhoea. 
They present the appearances of a new infection with some of 
or all its symptoms and expose the patient to all its complica- 
tions and sequelae. 

The recurrence of such an uncured gonorrhoea may be, as 
said before, weeks, months, or many years after all manifesta- 
tions of the disease have ceased. 

The exciting cause maybe: (1) Keduction of the patient's 
resistance by a debilitating disease, by exposure to inclement 
weather, by deprivation from proper food, by physical or mental 
overwork, by prolonged grief or anxiety ; (2) prolonged excite- 
ment of the genitalia, or excessive intercourse ; (3) dietetic irregu- 
larity, such as drinking more beer or other stimulants than was 
the patient's custom; (4) a traumatism of the genitals, provok- 
ing an inflammatory condition; (5) examination of the prostate, 
seminal vesicles, or Cowper's glands, when urinary disturbance 
causes the patient to seek professional advice ; (6) examination of 
the urethra, as, for instance, when a stricture has sufficiently 
advanced to impede the urinary stream; (7) marital reinfection. 

Whatever the exciting cause, the gross manifestations of the 
disease may be so marked and the appearance of gonococci so 
characteristic that the physician, unless he knows the patient 
very well, might believe, even if the patient is a colleague, that 
a new gonorrhoea has been recently contracted. While it is 
true that the infectious incident may have been forgotten, it is 
better to err on the side of charity and give the patient the bene- 
fit of the doubt. 

Irrigations, as described in Chapters III. and V., will, in the 
majority of such cases, bring about an abatement of the disease, 
and often in a very few days. But the cause for its recurrence 
remains and is likely to reproduce it at any time. Therefore it 
behooves us to study these causes now as far as is compatible 
within the limits of this book. 

When the recurrence is provoked by reduction of resistance 



170 THE IRRIGATION TREATMENT OF GONORRHOEA. 

from any cause, proper nutrition, protection from exposure to 
atmospheric inclemencies, abstinence from overwork must be 
prescribed in addition to local treatment. Grief and anxiety 
are, however, beyond the sphere of professional advice, unless it 
be in that sympathy and encouragement by which the physician 
exercises his noblest duty. 

In addition, these cases will require tonics. After several 
days of treatment, microscopical examination of the discharge 
and of the urine will serve as excellent guides to the locality of 
the residual infection. When the local manifestations have 
subsided or are reduced to a minimum, exploration of the ure- 
thra and its adnexa will usually confirm the microscopical diag- 
nosis. Before the case can be dismissed, these must be treated, 
and after the proper interval, the patient submitted to the tests 
mentioned in Chapter XIV. (The Proofs of Cure of Gonorrhoea). 

The second group of exciting causes of a gonorrhoeal recur- 
rence are perhaps the most difficult to ascertain. Few married 
men, except those lacking culture or refinement, will confess to 
genital dalliance with a partly willing female, such, for instance, 
as a well-developed, sensual-appearing servant. Yet some in 
whom the sexual sense, or lack of sense, is strongly pronounced 
are guilty of such acts, in which they perhaps preserve them- 
selves from the possible consequences of infection or the woman 
from impregnation by abstaining from gratification of the so 
stimulated impulse. A step further in this class is shown by 
those who indulge in psychic masturbation. They give way to 
invoked phantasms of sexual relations with women they see in 
public or even with creatures of the imagination. Whether 
these practices lead to appreciable ejaculation or only to its 
verge, the effect of the hyperemia is the same. 

Those who had sexual intercourse onceoftener than was their 
habit in a night can similarly produce an emptying of gono- 
cocci that long have lain residual upon the urethral mucosa, or 
stimulate them to renewed activity by the urethritis ex libidine 
that resulted. 

The irritated condition of the urethra which often obtains 
from the excesses committed shortly after marriage may pro- 
voke a recurrence of gonorrhoea, if the husband's urethral ad- 
nexa hold gonococci. An illustrative case may here be cited : 

A gentleman, aged 34, acquired gonorrhoea in his eighteenth 



171 

year. When he was twenty-eight he married, having had no 
manifestation of the disease for ten years. Shortly after his 
marriage, as so often happens, he had what appeared to be a 
very severe fresh attack of gonorrhoea. His wife was similarly 
affected. Conscious that for six months before he had not ex- 
posed himself to infection, and his wife but recently having been 
a virgin, he attributed their illness to that mysterious, albeit 
often quoted cause, a "strain," for which he sought no treat- 
ment until violent orcho-epididymitis bound him to his bed. 
It progressed to suppuration, which caused the destruction of 
one epididymis and testicle. 

After this he had no acute evidence of disease until five 
years later. His wife then had returned home after an absence 
of several weeks. Their first coitus was, within four days, fol- 
lowed by acute gonorrhoea in both. Never having been guilty 
of infidelity, he suspected her, with the usual result of a family 
disruption. This lasted until it was shown him that either or 
both could harbor gonococci for years without any appreciable 
manifestation thereof. In both, the disease yielded rapidly to 
irrigations. The wife, on subsequent examination, was found 
to be free from the disease. The husband, however, three 
weeks after responding negatively to all tests, when examined 
urethroscopically, showed some enlarged, gaping glands. Their 
contents being expressed with Kollmann's spatula, showed gon- 
ococci, which, with an adequately exciting cause, would have 
sufficed to produce an apparently fresh clap. After electrolysis 
of these glands the patient resumed relations with his wife and 
his usual mode of high living. Examination of the entire gen- 
ito-urinary apparatus six months later showed no abnormal con- 
dition, except, of course, the destroyed testicle and epididymis. 

The third group of causes for the recrudescence of residual 
gonorrhoea are those attributable to dietetic irregularities. A 
glass of beer or wine in excess of the usual quantity drunk, or 
ingestion of the vegetables that provoke oxaluria or phosphaturia 
in susceptible cases, may set up enough urethral irritation to 
reproduce the discharge. In Germany the urethral irritation 
from young white wine and beer is well-known to the laity, 
whence arose the familiar designation of " Biertripper. " In all 
the cases of this Biertripper I could examine gonococci were 
found; each of these patients, however, acknowledged having 
had gonorrhoea. No doubt can obtain but that such a distinct 
urethritis occurs in cases that have never had gonorrhoea; it 
has, however, not been my fortune to meet one. 

When such a urethritis db ingestis provokes gonorrhceal re- 



172 THE IRRIGATION TREATMENT OF GONORRHOEA. 

currence, success in treatment naturally is predicated upon pro- 
hibition of all irritating food, stimulants, and carbonated waters. 

Traumatisms, mentioned before as the fourth class of causes 
for the recurrence of gonorrhoea, explain themselves. It is not 
necessary that the traumatism to the genitals be applied directly 
to the region which harbors gonococci ; the inflammation result- 
ing can readily extend to it and there provoke the recurrence. 

The fifth division of cases in which a recurrence of gonor- 
rhoea is provoked is distinctly due to the physician's inevitable 
diagnostic procedure, as shown by the following typical outline : 
A gentleman beyond middle life experiences gradually dimin- 
ishing propulsive ability in expelling urine. The physician 
examines his prostate, and in so doing makes pressure upon it. 
While having his finger in the rectum, he completes his work 
by examining the seminal vesicles and Cowper's glands. If any 
of these adnexa harbor gonococci, from an infection of possibly 
many years ago, some can be emptied into the urethra by the 
manipulations necessary for a thorough examination. Ordi- 
narily the urethra is not infected thereby ; but if there be a point 
of weakened resistance in the urethra, acute gonorrhoea can re- 
sult from this mode of infection. 

The length of time in which gonococci can be harbored within 
the prostate, without in any way manif estating their presence 
to the patient, is well demonstrated by the following extreme 
case : 

A gentleman had an attack of gonorrhoea in his eighteenth 
year. At twenty-six he married. His wife bore him two healthy 
children. When he was forty-three years old, his wife, who 
had not become pregnant for ten years, was taken with salpin- 
gitis at about the same time that he became affected with evidence 
of prostatic enlargement, such as diminution of the force of the 
stream, frequent nocturnal urination and inability entirely to 
empty his bladder. Examination of the enlarged gland brought 
forth a very small quantity of grayish muco-pus, which was 
found replete with gonococci. 

So here is a case in which, for twenty -five years, the prostate 
held gonococci without any manifestation whatever, not even 
preventing the procreation of two healthy children. 

In the sixth class of cases auto-infection, from the use of an 
exploring instrument to discover a stricture or a catheter to re- 
lieve retention, is far more readily comprehensible. The instru- 



DIGITAL PALPATION OF THE URETHRAL ADNEXA. 173 

merit can impinge upon or scrape the mouth of an infarcted 
crypt, gland, or follicle and thus cause gonococci that have long 
lain residual therein, to be set free upon the mucosa. 

The seventh set of cases, those in which gonorrhoea is due 
to marital reinfection, are mentioned here only to remind the 
student of such a possibility. The importance thereof will bet- 
ter be considered more in detail under Residual Gonorrhoea in 
Women (Chapter XII.). 

The means for the diagnosis of these conditions and their 
treatment are outlined under the respective heads. 

Note : The cases cited in this chapter are quoted from my 
report in the Atlanta Medical and Surgical Journal, for Sep- 
tember, 1898. 



XI. DIGITAL PALPATION OF THE URETHRAL 

ADNEXA. 

As has been mentioned under the Complications of Gonor- 
rhoea, the posterior urethra, the prostate, and the seminal vesicles 
frequently become involved in gonorrhoea. Cowper's glands 
often escape. If infection of one or more of these adnexa is 
unheeded, the case is likely to be interminable, from uninter- 
rupted or occasional reinfection of the channel, as gonococci are 
carried to it from the organs mentioned. 

A greater part of each of these adnexa can be reached only 
through the rectum by the finger, not alone for diagnostic, but 
for therapeutic purposes as well. 

Digital exploration of the rectum, disagreeable and even 
painful as it sometimes is, cannot be avoided in the diagnosis 
and treatment of diseases of the seminal vesicles, the prostate, 
the base of the bladder, Cowper's glands, and the posterior 
urethra. 

1. Preparation of the Patient. — Whenever possible, the ex- 
amination should be made soon after the patient has evacuated 
his rectum. The presence of fecal masses or of a column of 
faeces renders the examination more disgusting than necessary. 
It also has a tendency to divert the physician's attention from 
his objective points. Many patients, especially if they have 
not defecated on the day of the examination, at once have a 



174 THE IRRIGATION TREATMENT OF GONORRHOEA. 

desire for stool when the finger is inserted. The straining in- 
cidental thereto may thwart the effort at examination. This 
may go so far as to oblige an interruption of the examination, 
that the patient may go to the closet. The immediate resump- 
tion of digital exploration thereafter is only a renewal of every- 
thing unpleasant connected with the procedure. In such a case, 
it is generally advisable to defer further examination to the fol- 
lowing day. Of course such prorogation cannot be considered 
when dealing with an acute case, or one* requiring immediate 
treatment, as in periprostatic or prostatic abscess. 

2. When possible the patient empties his bladder, preferably 
into two or three twelve-inch ignition tubes. Into one tube he 
passes 150 c.cgm. (about fl. 3 v.), which is estimated to carry 
with it all the washings from the anterior urethra that can be 
detached by the stream. The second, third, or more tubes, 
according to the capacity of the bladder and the time that has 
elapsed since the last urination, should then be filled. The last 
25 or 30 c.cgm. (about an ounce) should be voided into a sepa- 
rate tube, to ascertain whether the final expulsive efforts cause 
ejection of the contents of the prostate or seminal vesicles, as 
in urination-spermatorrhoea. As has been said before, separa- 
tion of the urine in this manner does not serve for absolute 
diagnostic accuracy, but it often proves a valuable aid thereto. 

Naturally, if the patient is severely strictured, or has incon- 
tinence from any cause, or retention from a much enlarged pros- 
tate, this preliminary step is omitted. 

3. Distending the Bladder. — When no contraindication 
thereto exists, the bladder may be filled with a warm four-per- 
cent, boric-acid solution. Besides distending the bladder for 
the purpose of facilitating prostatic examination, this is the 
easiest means of ascertaining vesical capacity. Except where 
a large prostate acts as a dam for residual urine, the catheter 
and hand syringe (such as the Guy on or Janet syringes) are 
preferable for such measurement. 

The use of boric acid for this purpose has other advantages, 
which will be mentioned further on (see 14). 

4. Position. — The method often advocated, of bending a pa- 
tient over a chair or the end of a table, is unsatisfactory. It 
obliges the surgeon to fix the pelvic viscera with his left hand, 
adding to the severe labor by the then necessary support of the 



DIGITAL PALPATION OF THE URETHRAL ADNEXA. 175 

abdomen. As many of the cases requiring examination and 
massage of the prostate are quite corpulent, their management 
in this position becomes impossible. Moreover, in painful pros- 
tatic conditions, it may cause a patient to faint, or in epileptics 
may provoke an attack during examination. 

For the above reasons and for convenience as well, it is best 
to examine all cases with the patient lying on his back on a 
couch or table, the knees somewhat raised, and the heel of the 
right foot resting in the hollow of the left. When the trousers 
are then drawn down to the ankles, there will be no difficulty 
in extending the knees as far apart as possible. A cushion 
under the buttocks is objectionable, as it throws the weight of 
the abdomen upward, which draws with it the pelvic viscera. 
In so doing it naturally renders the distance between the anus 
and the prostate greater, and thus unnecessarily enhances the 
difficulty of examination. 

Instead of a cushion, a towel should be placed under the 
buttocks and left there, while the shirt is drawn up to beyond 
the hips. Most prostatic patients are very susceptible to change 
of temperature ; the towel will protect their bared nates from 
coming into contact with the cold leather of the table or sofa. 
The same towel should be used by the patient for cleansing 
his anus of the lubricant employed in the examination. The 
majority will appreciate this care for their comfort and the 
cleanliness of their linen. They will also appreciate it highly if 
a clean towel is placed under their heads, so that the hair is pro- 
tected from contact with the place where other patients have lain. 

The preference for a sofa over a table for prostatic examina- 
tion lies partly in the fact that the familiar piece of furniture 
inspires less dread than does the more strictly surgical imple- 
ment; consequently there is less likelihood of spasm of the 
sphincter ani, which fear of pain is prone to induce. Again, 
the surgeon, being in the bent posture, can exercise greater 
thoroughness with less manifestation of physical effort than he 
could if the patient were on a table. 

It is well to cover the lower third of the sofa with a tough 
rug, as the position of the patient with his knees drawn up and 
extended as widely apart as possible exposes his feet to slip- 
ping, and the sofa to being cut or at least mutilated by the 
patient's heels. 



176 THE IRRIGATION TREATMENT OF GONORRHOEA. 

5. Preparation of the Finger, — For some time I used espe- 
cially thin rubber cots to protect the index from contact with the 
rectum. No matter how thin, they always, by their presence, 
obtund sensation. Then, too, the thickened band at the open 
end constricts the finger, and this, producing some numbness by 
venous stasis, also renders the touch less acute. 

In addition to thus reducing the finger's sensitiveness, these 
cots are difficult to remove. Even slitting them with a probe- 
pointed knife does not prevent the fecal soiling one sought to 
avoid by their use, for it is but crowded down their slippery 
surface to the root of the finger. 

After discarding the finger-cots I for a while used short 
condoms ("rubber caps," Eichelcondome, capotes anglaises). 
The touch through them was somewhat better than through the 
equally thin cots. But their looseness about the finger often 
caused them to be swept off and left just within the sphincter 
ani. Attempts to fasten them with rubber bands produced the 
same constriction and consequent numbness which led the finger- 
cots to be discarded. Moreover the manufacture, importation, 
or sale of short condoms is forbidden by law ; therefore there is 
something disagreeable in the necessarily surreptitious manner 
of obtaining them. 

The use of common soap for the finger approaches perfec- 
tion in rectal examination. The points most requiring protec- 
tion are the sulcus beneath the nail and the matrix at its base. 
Of course no one in active genito-urinary work thinks of begin- 
ning his day's labors without filing and pumice-stoning his nails 
as close to the skin as possible. Still, a minute subungual 
furrow is inevitable, and it is in this furrow that the slightest 
trace of fecal odor makes itself so unpleasantly distinct, even 
after the most vigorous scrubbing. The rival of this spot for 
fecal defilement is the slightly overhanging skin at the matrix 
of the nail, which, despite the most assiduous trimming, cannot 
be kept down or even. Most genito-urinary practitioners who 
treat many cases daily, wash and scrub their hands very many 
times during office hours. It is true that at one of the large 
European clinics I saw a gentleman with a little bowl before 
him, containing about eight ounces of 1 : 1,000 mercuric bi- 
chloride solution. After each patient he dipped the tips of his 
fingers into this bowl and dried them on a towel — the one towel 



DIGITAL PALPATION OF THE URETHRAL ADNEXA. 177 

serving him for perhaps a hundred cases. That he did not 
infect himself or carry infection from one patient to another 
could have been but a matter of luck. The matrices of his nails, 
too, were just as ragged as if he had used as much hot water 
and soap as do others. 

When soap is used to protect the finger, the cake should be 
slightly moistened and then scraped with the index, in such a 
manner as to fill the matrix, as well as the interval between the 
nail and the skin at the tip of the finger. But after this is 
scrubbed off ever so vigorously and thoroughly, a match or 
toothpick scraped through these spaces will acquire a decided 
fecal odor. This is possibly due to some of the excremental 
constituents penetrating the soap. 

When soap is used for this purpose, the finger can be rid of 
its bad smell by first thoroughly scrubbing it in intensely hot, 
running water ; then crushing a few grains of potassic perman- 
ganate about the finger with the left hand. After the ozone- 
like smell of the permanganate becomes evident, the stain is 
removed with oxalic acid and numerous rinsings. The slight 
cuts and chaps one occasionally acquires despite the greatest 
care then become too painfully evident to pass unobserved. 

Since January, 1899, 1 have used flexible collodion for finger 
protection in rectal examinations of the genito-urinary adnexa. 
It covers the finger tip with a pellicle which, if properly ap- 
plied, does not break within the rectum. It in no wise obtunds 
sensation. The fingerfe els through it as acutely as if it were 
not covered at all. Only after the examination, when the finger 
is vigorously scrubbed with soap and very hot water, does the 
collodion separate and then in large flakes. These flakes are 
&ve or six times thicker than elsewhere, at the subungual space 
and at the matrix, the very points most easily invaded by rectal 
contents. Any bits of collodion that may remain are quickly 
removed by a little ether, which also dissolves the fats that hold 
the minute fecal masses adherent to the finger. Thus cleanli- 
ness after rectal exploration is easily obtained. 

The best manner of securing a desirable coat for the finger 
is by dipping it into an ounce salt-mouth containing the flexible 
collodion. As soon as the first coat has dried, a second and 
finally a third may be applied in the same manner. This will 
give additional security and not interfere with sensation. 
12 



178 THE IRRIGATION TREATMENT OF GONORRHOEA. 

Special care should be exercised in not attempting to insert the 
finger before all parts of its collodion covering are perfectly dry. 
It may require several minutes to insure solidity of the little 
blebs that form between the finger and the collodion. If these 
are overlooked and the finger is inserted while they still exist, 
they will break in the rectum and produce severe burning as the 
ether of the collodion touches the mucosa. Besides the un- 
necessary suffering thus inflicted upon the patient, the points at 
which the collodion has so been broken will cause it to peel off 
in shreds and leave the finger exposed to contamination by the 
fecal odor. 

6. Protecting the Genitals. — The patient being in position, 
with his trousers and drawers well drawn down to his ankles, 
as described under 4, the surgeon raises the scrotum with his 
left hand, so that the genitalia be not unnecessarily soiled with 
the lubricant that is now applied to the collodion-covered finger. 

7. Lubricating the Finger and Anus. — When the entire right 
index finger is coated with collodion, as much lubrichondrin as 
can be taken up by it is placed upon the anus. 

8. Inserting the Finger. — Most of the works I have been able 
to search are exceedingly meagre in their description of the 
entire technique of rectal digital examination. The most ex- 
plicit are Hoffmann, Guterbock, and von Frisch. 

The first ] says : " The examining index finger, its vola turned 
upward, well oiled, is slowly inserted with gyrating motions, 
into the anus, after a thorough evacuation of the rectum." 

Guterbock 2 offers but little more detail : " The oiled, care- 
fully inserted finger feels, after traversing the excavation of the 
rectum that lies closely over the anus, first the bulb which offers 
somewhat increased resistance." 

These directions certainly suffice for surgeons who have been 
well instructed. But not all have had the educational advan- 
tages that make further details superfluous. 

Professor von Frisch, 3 who describes the lower rectal findings 

] Egon Hoffmann: "Die Krankheiten der Prostata." Zuelzer and Ober- 
laender's Klinisches Handbuch der Harn- und Sexualorgane, vol. iii., p. 3, 
Leipzig, 1894. 

2 Paul Guterbock : Die Krankheiten der Harnrohre und Prostata, p. 203, 
Leipzig and Vienna, 1890. 

3 A. von Frisch : Die Krankheiten der Prostata, Holder, Vienna, 1899. 



DIGITAL PALPATION OF THE URETHRAL ADNEXA. 1 1 9 

more in detail, offers the valuable advice that the hairs about 
the auus be separated before attempting to insert the finger. 
This additional precaution against giving the patient pain by 
dragging the hairs into the rectum will be especially appreci- 
ated by those who have been examined before without this care. 
Moreover, the examination will be easier to the physician be- 
cause of the absence of the pain which dragging upon the hairs 
would produce and the anal rigidity it would evoke. 

It is hardly necessary to call attention to the need of care- 
fully avoiding any fissures or erosions about the anus, lest pain 
be given and aggravation of these conditions produced thereby. 

The examiner's index finger, protected with flexible collodion, 
penetrates the mass of lubricant he has placed upon the anus. 
At the moment of an interval between expiration and just before 
beginning inspiration, he allows the finger to glide into the 
rectum. Any hesitation, gyration, or force will cause the pa- 
tient to contract the sphincter and violently clasp the thighs to- 
gether. The patient will certainly esteem more the efforts of 
one who, causing less or no pain, consequently performs better 
and more thorough work. 

9. Releasing the Scrotum. — The left hand now being required 
to fix the pelvic viscera, it allows the scrotum to fall gently 
into the space between the right thumb and the extended rignt 
index finger. 

10. Fixing the Pelvic Viscera. — The left hand is curved, the 
outer margin of the thumb placed about half an inch above and 
parallel to the pubis. By increasing pressure downward and 
backward, the pelvic contents are rendered as immovable as 
possible and approached, as far as can be, to the finger within 
the rectum. 

11. Raising the Perineum. — When the index finger is about 
to approach the mass of lubricant on the anus the middle, ring, 
and little fingers are flexed ; when the index penetrates the rectum, 
the other fingers are tightly closed upon the palm. The dorsal 
aspect of their basilar phalanges presses against the perineum 
as the index ingresses more deeply into the rectum. Mean- 
while the forearm is depressed between the thighs until the 
elbow almost touches the couch upon which the patient lies. As 
this is being done the perineum is crowded upward, the surgeon 
avoiding contact with the tip of the coccyx. 



180 THE IRRIGATION TREATMENT OF GONORRHOEA. 

12. Position of the Thumb. — If the thumb is doubled with 
the other fingers, it will be arrested by the ascending ramus of 
the pubis and thus materially limit the upward progress of the 
index within the rectum. When the hand is turned to avoid 
this, the knuckle of the thumb will impinge upon the anterior 
part of the perineum and give the patient unnecessary pain. It 
is therefore well to pass the thumb as high up as possible along 
the scrotum, while the index finger glides into the rectum. 

13. Palpation. — The index finger, as it progresses into the 
rectum, ordinarily finds : (a) the excavation of the rectum, almost 
immediately above the anus ; (b) the bulb which offers a some- 
what increased resistance; (c) the pars nuda urethrse; (d) the 
apex of the rectal surface of the prostate; (e) the lobes of the 
prostate. 

Even a short index finger, when the proper technique is 
carefully followed, can pass its tip about the topmost margins 
of the prostate and even beyond them, as in health the extreme 
upper curves of the prostatic lobes are between 7 and 8 cm. from 
the external anal margin. 

With increasing practice the physician will learn to seek for 
the seminal vesicles and the ampullae of the vasa beyond the 
prostate, and Cowper's glands below it, during the same rectal 
exploration. Ordinarily these adnexa cannot be found in health. 

If prostatic enlargement always proceeded in its rectal direc- 
tion alone, digital palpation would suffice for diagnosis. But 
as the diseased prostate can increase in size in any direction, 
other palpatory means than that furnished by the finger will be 
required. 

In this a silver catheter with a short curve or with the 
Mercier beak will prove of valuable aid. If, the finger being in 
the rectum, such a catheter is inserted into the bladder, its tip 
is distinctly felt as it passes through the bulbous portion and 
with equal distinctness as it penetrates the pars nuda. It then 
disappears until its tip proceeds just beyond the prostate. A 
tight rubber band may then be slipped over the catheter just 
where it emerges from the meatus, while the penis is crowded 
as far back toward the pubis as possible. Then withdrawing 
the catheter, its point is concealed by the prostate from the 
finger in the rectum. Still further extracting the catheter, an- 
other rubber band is slipped over its shaft at the moment when 



DIGITAL PALPATION OF THE URETHRAL ADNEXA. 181 

the finger within the rectum first feels it in the pars nuda, be- 
neath the prostate. The distance between the two rubber bands 
will give a sufficiently precise measurement of the length of the 
prostatic urethra. This consequently will also reveal increase 
in the length of the prostate. 

The thickness of the prostate and variations therein are dis- 
cernible in the same manner. An aid to this is in close obser- 
vation of the shaft of the catheter. Grossly it may be said that 
the less the prostate crowds into the bladder, the more will the 
external end of the catheter point upward, and the larger the 
prostatic ingression of the bladder, the more will it be inclined 
downward between the patient's thighs. Naturally this applies 
only when the shaft of the catheter has passed the prostatic ure- 
thra. 

The cystoscope is doubtless the most valuable instrument 
for prostatic examination, when its encroachment is principally 
toward the bladder. But as cystoscopy is not within the prov- 
ince of the present effort, we may rest at its mention. 

14. Emptying the Bladder. — The discomfort at least, if there 
be no severe pain incidental to rectal palpation, ordinarily 
affects the patient very much. Often the pupils will be found 
quite dilated, the pulse weak, and respiration disturbed. Some 
men grow very pale and are suffused with perspiration in con- 
sequence of the examination. It is well to have the patient 
remain in the position of the examination, but with extended 
legs, for at least five minutes, or at all events until all symp- 
toms of the disturbance have passed off. He is then allowed to 
rise, and, in order to divert his attention, he is ordered to cleanse 
carefully the region about his anus of the lubricant lest it soil 
his linen. 

It will be unwise to ask the patient to empty his blad- 
der at once. The examination ordinarily produces a pro- 
longed spasm of the compressor, which does not subside for 
five or ten minutes, and only then can the patient void the blad- 
der contents. 

15. Microscopical Examination. — When boric-acid solution or 
sterilized water has been used to dilate the bladder, it shows by 
its turbidity, when passed, that the prostatic contents or those 
of the seminal vesicles have been pressed out during the ex- 
amination. If the palpation has been prolonged, the water 



182 THE IRRIGATION TREATMENT OF GONORRHOEA. 

may also contain a little urine. Shreds from the bladder or 
urethra may also float in the liquid. To complete the diag- 
nosis, the fluid should be sedimented or centrifuged and ex- 
amined microscopically. By this means a guide to the organ 
affected will be obtained. 

If the prostate is not so much enlarged as to preclude sepa- 
rate examination of the other urethral adnexa that can be reached 
through the rectum, these should be examined preferably a day 
or two after each other. While their shape and gross changes 
can be elicited at one examination when extreme prostatic en- 
largement does not prevent, the contents expressed from them 
are mingled in the urethra, and therefore the specimens obtained 
must be examined together. 

The technique of separate examination of each of the other 
urethral adnexa is performed as follows : 

16. Seminal Vesicles. — All the steps for examination of the 
prostate are taken. The finger passes the prostate without 
making any pressure upon it. Above the prostate and some- 
what external to its sides, the vesicles project along the bladder. 
In health the vesicles cannot often be felt ; in disease they pre- 
sent as somewhat enlarged sausage-shaped, soft or hard bodies. 
Occasionally distinct knots are felt in them. Their stripping 
or " milking " is performed by strokes similar to those used in 
massage of the prostate. Fuller's excellent work on "Disorders 
of the Male Sexual Organs " (Lea, 1895) is devoted to the study 
of diseases of the seminal vesicles, and to this work the reader 
is referred for exhaustive information. 

17. The Posterior Urethra. — For examination of as much of 
the posterior urethra as can be reached through the rectum, the 
patient's bladder is first irrigated until the boric acid used is 
returned perfectly clear. Then the bladder is filled with dis- 
tilled water, and the patient prepared as for a prostatic examina- 
tion. The examining finger, however, leaves the prostate without 
pressing upon it, and exercises all its pressure on such parts of 
the urethra as are exposed, endeavoring at each stroke to com- 
press the urethra more closely against the pubis. The distilled 
water then passed will contain such shreds, flakes, filaments, 
and granules as the urinary stream and irrigation could not de- 
tach from the walls of the posterior urethra. While the pres- 
ence of gonococci in this " expression fluid " will serve to assist 



DIGITAL PALPATION OF THE URETHRAL ADNEXA. 183 

in diagnosis, differentiation is not complete without urethro- 
scope examination. 

18. Gowpers Glands. — Although these glands are not fre- 
quently involved, their examination should not be omitted. In 
health they are so minute as to be barely or not at all percepti- 
ble to the examining finger in the rectum. When it is engaged 
between the internal and external sphincter, somewhat doubled 
upon itself and carried forward in the direction of the perineal 
raphe, at either side thereof, these glands will be found. 

In many cases of prostatic enlargement, of acute vesiculitis 
or cystitis, the bladder will not tolerate the preliminary disten- 
tion mentioned above. The examination then must be made 
without this valuable assistance, and it consequently becomes 
more difficult. 

It is particularly when the bladder is dilated that some 
of the contents of the adnexa escape from the meatus when 
pressure is made upon them. The discharge so obtained is 
then easily taken upon a cover-glass, and prepared for micro- 
scopical examination. 

Massage of the prostate and stripping the seminal vesicles for 
therapeutic purposes are performed in practically the same man- 
ner. The tip of the finger engages, as high up as possible, 
the organ to be treated. At first gentle, slow strokes downward 
and toward the mesian line are made ; these strokes are gradu- 
ally increased in firmness and continued until the flattening of 
the organs shows that their removable contents are expressed, or 
at least as long as the patient can bear the manipulation. 

In many cases the efficacy of prostatic massage can be en- 
hanced by steadying the vesical side of the prostate by means 
of a sound, preferably of the Guy on curve. It requires, how- 
ever, some dexterity to so incline the sound laterally within the 
bladder that it rests upon and thereby to a degree fixes the 
prostatic lobe that is being treated through the rectum. 

The student need hardly be reminded that the first rectal 
manipulation is likely to be quite painful. Therefore extreme 
gentleness is as requisite here as it is in all other genito-urinary 
work. The relief patients experience is in most instances so 
great that they willingly submit to what soon grows to be a 
mere inconvenience. Indeed, many of them urge its repetition 
at shorter intervals than the judgment of the physician prescribes. 



184: THE IRRIGATION TREATMENT OF GONORRHOEA. 

Only rarely can these organs bear massage or stripping oftener 
than twice or at most three times weekly. In exceptional cases 
daily massage may be required. 



XII. RESIDUAL GONORRHCEA IN WOMEN. 

Gynecologists have, in recent years, well exposed the dis- 
astrous consequences of gonorrhoea when it invades the womb 
and the organs beyond. They have also shown how amenable 
the disease is to treatment before it has passed beyond the 
vagina. 

Many a woman, however, subjected to the older methods of 
treatment is only apparently cured. In consequence, she may 
at any time near or remote, infect a man, if the circumstances are 
propitious therefor. This form of the disease, which seems to 
be best denned by the term "residual gonorrhoea," has appar- 
ently not received the attention in literature that its importance 
merits. 

In considering residual gonorrhoea in women, the disease 
adulterously acquired by the husband or wife may, in certain 
cases, be within the range of possibility. But adultery does not 
contribute to the understanding of residual gonorrhoea, unless 
the infection of the husband occurs long after all manifestations 
of the attack have subsided. 

Again, the possibility of auto-infection on the part of the 
husband, who had gonorrhoea before marriage, as outlined in 
Chapter X., can explain a gonorrhoea in his wife, who may, if 
the husband is ignorant of such a possibility, be unjustly ac- 
cused of infidelity. 

The field for speculation and theorization in this connection 
is extremely wide, and most frequently no conclusions can be 
reached therefrom. Certain facts, however, are known. Among 
these are the not inconsiderable number of women who marry 
men while the latter are not cured of gonorrhoea. Many of 
these women, for at least a period of their lives, enjoy a species 
of immunity. Their resistance to gonorrhceal infection may at 
any time become impaired by slight causes. If the case re- 
ceives prompt and energetic treatment, no residual gonorrhoea 
will result. 



RESIDUAL GONORRHOEA IN WOMEN. 185 

Many practitioners have been obliged to treat vaginitis in 
recently married women. Often this is so slight that it subsides 
with the employment of an antiseptic wash, a lead and opium 
lotion, or injections only of hot water. Since familiarity of prac- 
titioners with bacteriological staining has become greater, many 
of these cases are found to contain gonococci. Anti-gonorrhceal 
treatment being employed, the patients recover. 

The majority of brides, however, do not inform any one of 
their ailments, which they conclude are the natural consequences 
of sexual intercourse. In very many cases, especially if the 
husband is considerately abstinent for a while, the infection ap- 
parently yields to the vis medicatrix naturce. 

In some cases the inflammation is so slight and its resultant 
discharge so scanty that, when gonococci are found in the mi- 
nute excess of normal secretion, Guiard's blennorrhagie cJironique 
d'emblee is suggested. 

Most Avomen, when brought for examination under suspicion 
of having infected their husbands, will unhesitatingly acknowl- 
edge having had leucorrhcea once or oftener in their lives. 
Some, however, have had so slight vaginal discharges that they 
attracted no attention because of that marvellous carelessness 
regarding the genitals which so widely extends in all classes of 
society. Whether these discharges were the result of gonor- 
rhoea! infection or were leucorrhoeas due to other causes, is of 
course impossible to determine after they have passed off. 

The cases that must be considered as residual present no ex- 
ternal manifestations whatever. The urethra, the labia, the 
vagina, the cul-de-sac, and the os all appear perfectly normal. 
If consideration of the woman's health stops here, and the hus- 
band is cured, he is likely at any time to again contract the dis- 
ease from his wife, without any crass evidences of the disease 
becoming manifest in her. 

To illustrate as graphically as is possible to me, the condi- 
tions above outlined, I transcribe several typical cases from my 
records : 

J. B aged 35, banker, in apparent good health, with no 

family or personal record of disease of any kind, was sent by 
a colleague on November 5th, 1897. The patient said that 
for three years he had been cohabiting with but one woman, 
of whose fidelity he had no doubt. Three weeks before, he had, 



186 THE IRRIGATION TREATMENT OF GONORRHOEA. 

four days after intercourse, experienced slight burning on uri- 
nation; soon a slight mucoid excess set in. The discharge 
rapidly became yellowish, then greenish-yellow, mixed with 
blood. With the increase of the discharge the pain on urination 
increased ; painful erections were almost continual every night ; 
the right epididymis was enlarged, not much hardened, but ex- 
quisitely sensitive. The last-mentioned complication caused 
him to be referred to me. The patient had been treated by the 
internal administration of balsams and various hand injections. 

On examination of the discharge it was found to contain 
very little mucus, few leucocytes, few epithelial cells, and most 
of these from the second layer of the urethra. Everywhere the 
field was thick with pus cells, of which many seemed ready to 
burst from their repletion with gonococci. There were also 
many extracellular gonococci between the pus cells and some 
attached to the epithelial scales. 

In brief, it was a distinct case of gonorrhoea. Irrigations 
and strapping the testicle enabled the patient to be dismissed 
from treatment on November 23d, 1897 — i.e., eighteen days after 
his first visit. Beer and champagne did not reproduce the dis- 
charge ; injection of silver nitrate produced a non-microbic dis- 
charge lasting ten hours; coitus with a condom showed the 
semen to be normal; expression of the prostate and seminal 
vesicles proved freedom from infection of these organs; these 
tests were made a week apart. Then, a week later, a urethro- 
scope examination showed a healthy urethra. 

On March 20th, 1898, the patient was again sent to me with 
some pain on urination, slight mucoid discharge easily express- 
ible from the somewhat tumefied lips of the meatus. The first 
urine was turbid and contained coarse filaments, which sank 
rapidly to the bottom. The second urine was clear. 

Microscopical examination of the discharge showed it to con- 
tain several groups of intracellular gonococci. 

The patient assured me that he had cohabited with no other 
woman. His last intercourse had been four days previously, 
being two days before she began to menstruate, at which epoch 
she was more than ordinately sensual. They had not committed 
sexual excesses. 

Under irrigations this discharge and all other symptoms 
ceased in five days. 

During this time he told me that his mistress confessed to 
having been unfaithful to him about six months before, with a 
married man, whom he knew. The one-time partner of his 
mistress's favors confirmed her confession, but averred that he 
never had had any venereal disease. 

I suggested that if my patient had never been infected be : 
fore, possibly his mistress had, previous to their acquaintance, 
and that she might unconsciously be carrying a residual gonor- 



RESIDUAL GOXORRHCEA IN WOMEN. 187 

rhoea, which from the hyperemia incidental to the pre- and 
post-menstrual days would become manifest. He then wrote 
her, severing their relations. She came to his office and in tears 
violently protested against being cast off. In the heat of her 
asseverations, she confessed to having cohabited with a number 
of men, whose names she revealed, so that he might assure him- 
self that none of them had been infected by her. 

On her insistence that she be examined in his presence, he 
brought her to me. 

To safeguard my pos-ition regarding what might otherwise 
imply a violation of professional confidence, I asked whether 
she were willing that I tell him my findings in her presence. 
To this she promptly consented. 

On examination, I found her genitalia in apparently per- 
fect health. Careful scrapings from the introitus, Bartholini's 
glands, the meatus, the vaginal walls, the cul-de-sac, the cervix, 
all showed normal epithelium, some mucus, and the usual vaginal 
bacteria. 

I then carefully irrigated the genitalia with hot boric-acid 
solution, sterilized ray hands, and packed the vagina with steril- 
ized cotton tampons soaked in sterilized glycerin. On re- 
moving these forty -eight hours later, I found a slight excess of 
whitish discharge upon the small tampon that had rested in the 
cul-de-sac and some slight oozing from the os. Examination of 
these discharges, so evoked from the submucous layers, was 
found to contain distinct groups of gonococci. 

The patient then told her lover, in my presence, that about 
a year before she first knew him, she had had a slight vaginal 
discharge, which had been diagnosed as leucorrhcea; this had 
promptly yielded to treatment. As an explanation for infecting 
him and not others, she offered that he was the only one with 
whom she experienced an orgasm, while she merely submitted 
to the others for the sake of financial gain. 

A similar case was brought me three years ago. 

A young married woman infected her lover. She confessed 
"to having been cured of gonorrhoea acquired as a result of her 
first adultery, while her husband was on a long voyage. He 
was never infected by her. She said that though her husband 
was sexually more potent than her lover, and physically better 
developed, he never produced an orgasm in her. This she at- 
tributed to her dislike for him. Each coitus with her lover, 
however, was complete. 

Examination revealed an exceedingly slight endocervicitis 
which, however, contained no gonococci. Only upon curetting 
the cervix, some discharge was obtained containing Neisser's 
specific microbe of gonorrhoea. In this case it seemed safe to 



188 THE IRRIGATION TREATMENT OF GONORRHOEA. 

say that the spasm of the orgasm discharged in this instance 
gonococci, which reached the lover's meatus. 

In a third case, seen with a colleague, the patient was a 
young woman, who claimed to suffer from occasional eroto- 
mania. When the condition was severe she assumed the part 
of a prostitute. Frequent cohabitation did not relieve the de- 
sire, unless the man's physique or mentality especially pleased 
her. Then coitus produced an orgasm. She was sure, when- 
ever this occurred, that she had infected the man. Her phy- 
sician told me that she had sent him a number of patients, for 
whose treatment she had paid, whenever the patient would per- 
mit it. She unhesitatingly related that she had had gonorrhoea 
four years previous to consultation. 

Examination evinced no excess of secretion, but a thorough 
curettage revealed that the deeper uterine mucosa harbored 
gonococci. This young woman, though continuing her course, 
afterward infected no others. 

A number of similar cases could be thus sketched to warrant 
the following deductions : 

(1) A woman can have residual gonorrhoea, without any ex- 
ternal manifestations. (2) A woman with residual gonorrhoea is 
more likely to infect a man cohabiting with her during the hy- 
persemia immediately preceding or still remaining after men- 
struation. (3) The likelihood of infection is probably greater if 
the coitus produces an orgasm in the woman. (4) Packing the 
cul-de-sac, as employed in the first case cited, may produce a 
slight discharge, revealing the submucous habitat of gonococci. 
(5) A submucous intra-uterine habitat of gonococci can be 
reached only by thorough curettage. (6) No woman should be 
pronounced cured of gonorrhoea until the osmosis test men- 
tioned above (4) has proved negative, and until expression of 
the urethra and Bartholini's glands, and scrapings from the 
cervix and uterine lining are proven to be free from gonococci. 

Note : This chapter is elaborated from an article I contrib- 
uted to the American Journal of Surgery and Gynecology (St. 
Louis), May, 1898. 

XIII. URETHROSCOPY. 

As has been repeatedly observed in the preceding chapters, a 
diagnosis of a chronic urethral disease cannot be even approxi- 
mately complete without visual examination of the channel. 



URETHROSCOPY. 189 

Obedient to surgical principles, no instrument may be in- 
troduced into the urethra while it is acutely inflamed. The only 
exceptions thereto are when a foreign body requires removal or 
when retention demands relief by the catheter, after other means 
of voiding the bladder have failed. 

In Chapter VIII. (Chronic Gonorrhoea) mention was made 
of the fact that without the aid of the urethroscope, all treat- 
ment of chronic urethral diseases must be tentative. With its 
assistance, the diagnosis can be made early, the treatment di- 
rected to the cause, and recovery expedited. 

But as easy as urethroscopy is, and as simple as its tech- 
nique has become, it can be acquired only most laboriously 
from written descriptions. The certainty of diagnosis it gives, 
however, is worth all the efforts devoted to acquiring it. In 
this it does not differ from other instruments of precision, such 
as the ophthalmoscope, the laryngoscope, etc., except that its 
manipulations are less difficult. 

The technique of urethroscopy can be most readily acquired 
by a few lessons from a colleague, who has been properly in- 
structed. A recognition of the multifarious conditions seen and 
their diagnostic interpretation can come only with experience. 
All efforts to pictorially present the urethral conditions have 
hitherto failed, at least, in being of use to the beginner. The 
essential difficulty seems in the reproduction of the colors, 
which are seen in the urethra under electric illumination. The 
pictures lithographed all appear too lurid, when an attempt to 
reproduce them is made. Exceptions thereto are the sectional 
colored pictures illustrating Oberlaender's 1 work, but as they are 
schematic, showing the walls of the urethra in section, they are 
of use only, and of most valuable use, to the urethroscopist of 
some experience. Kollmann's black and white photographs of 
the urethra are also invaluable to the advanced urethroscopist; 
it would certainly be desirable if the method of photographing 
the urethra devised by him were in the hands of all genito-uri- 
nary specialists, whose records and reports would be vastly en- 
hanced in value thereby. 

The reasons wherefor the urethroscope is not more generally 
used seem to be because: (1) Of the complicated character of 

1 Oberlaender: Lehrbuch der Urethroskopie, Thieme, Leipzig, 1893. 



190 THE IRRIGATION TREATMENT OF GONORRHOEA. 

the instruments for direct illumination; (2) of defective light- 
ing; (3) of the high cost of the instrumentarium. 

The consequence is, that the treatment of chronic gonorrhoea 
continues to be with some the most unhappy guesswork. To 
others it is a hopeless task, undertaken with misgiviDgs and 
discarded in desperation. What wonder then that the quacks 
make this their favored field, to begin with promises, to end 
with the patient's purse ! The immense number of men whose 
lives are rendered miserable and abbreviated by chronic gonor- 
rhoea, make all efforts on their behalf, and on behalf of their 
wives and children, worthy of most serious consideration. 

Manifestly then, an instrument is necessary to show the 
practitioner the exact location and precise character of the dis- 
ease. The instrument must effectively do its work, must be 
simple in construction, easy of use, not prone to get out of order, 
and always reliable. 

If the opinion of those who honor me by calling me their 
fellow-specialist is a guide, as it is on other matters, all these 
ends are accomplished by the urethroscope I had the privilege 
of publicly demonstrating for the first time before our Genito- 
urinary Section of the New York Academy of Medicine on 
March 14th, 1899. 

This instrument, made for me by the Electro-Surgical Com- 
pany, consists of urethrosbopic tubes, running from Nos. 24 to 32 




Fig. 53.— Urethroscope Tubes. 

F. In general appearance they differ little from the Nitze-Ober- 
laender tubes with burnished ends as modified by Kollmann. 
This modification permits urethral examination from behind for- 
ward as well as from before backward. The disc at the visual 
end is, however, larger, to safely hold the spur for easy and firm 
attachment of the light-carrier and the megaloscope. 

Each tube is provided with an obturator, stamped on the 
handle to correspond with the tube to which it belongs. The 
distal end closes the urethral tube to permit its easy introduc- 



URETHROSCOPY. 



191 



tion, and lias a deep slit corresponding with a similar slit in 
the handle. This slit permits air to readily enter the tube, 
facilitating the removal of the obturator by then preventing any 
suction upon the urethral mucosa. 




Fig. 54.— Obturator. 



The light-carrier is a delicate but very firm strip containing 
the insulated wires that illuminate the lamp which is enclosed 
in a glass capsule. By this means bright light is brought 
into almost immediate contact with the spots to be examined, be 
they ever so small. At its proximal end the light-carrier has 
an expansion, which can readily be attached to the spur on the 
disc of the urethroscopic tube. From the expansion the in- 
sulated connections for the conducting wires project, but are so 




Fig. 65.— Light-Carrier. 

curved that they do not encroach upon the visual orifice of the 
urethral tube. 

The light-carrier in general appearance resembles the one 
used in the Nitze-Oberlaender urethroscope. It differs essen- 
tially, however, in that the lamp gives no appreciable heat, and 
consequently requires none of the cumbersome water-cooling 
arrangements that are necessary when an uncovered light is used. 
Furthermore, the lamp being fixed permanently at its end, is 
not exposed to twisting and short-circuiting, as happens almost 
continually with what hitherto was the best instrument for direct 
illumination. Nor is this lamp likely to burn out, unless the 
most gross carelessness is employed. 

Moreover, the light being enclosed in glass, permits the lamp 
to remain in place while swabbing the secretions from the urethra, 
performing cauterizations, slitting infiltrated glands, electrolysis, 
finding the opening of devious strictures, and every other diag- 
nostic and remedial procedure, all under the guidance of sight. 



192 THE IRRIGATION TREATMENT OF GONORRHOEA. 




The megaloscope is a series of lenses combined in a short 
tube, attachable by a ring to the spur on the disc. By 
means of the megaloscope, whose focus is easily changed, the 
view of every part of the urethra can be im- 
mensely magnified. The interspace between 
the visual orifice of the tube and the objective 
end of the megaloscope is three-fourths of an 
inch, to allow the introduction of instruments 
for operative procedures within the urethra. 

The urethroscope, with all the appurte- 
nances described, is enclosed in a case, whose 
total weight is about ten pounds. At the price 
at which the fresh dry cells are furnished, the 
cost of each urethroscopy is within half a cent. 

The foregoing shows that I have devised 
only improvements upon and mainly simplifica- 
tions of existing instruments. This urethroscope 
in its entirety, however, differs from the Nitze- 
Oberlaender apparatus in being easily transport- 
able, thus making it unnecessary to reserve a 
room in the office suite for this purpose, or of having an urethro- 
scope outfit for each room. 

When science and benefit to humanity are objective points, 
the question of priority is of no importance. Still it may be 
well to sketch the history of this instrument. In 1894 1 expressed 
to my friend and fellow-student, Dr. Henry Koch, the opinion 
that urethroscopy by direct illumination would not find favor 
with the profession unless the water-cooling arrangement could 
be dispensed with and the apparatus further simplified as to the 
source of illumination and in other regards. It seemed to me 
that the first step in this direction would be in the production 
of a sufficiently small encapsulated light. Late in 1898 Dr. 
Koch found that Mr. W. C. Preston could make such a light. 
Experiments with it led me to suggest the construction of the 
apparatus above described. 1 

The technique of urethroscopy, as suggested before, is exceed- 



FlG. 56. 



1 As this book is going to press, Messrs. George Tiemann & Company, of 
New York, are placing before the profession a urethroscopic apparatus embrac- 
ing all the improvements that continued study and experience have demon- 
strated to be necessary for aseptic, effective, and convenient work. 



URETHROSCOPY. 193 

ingly simple. One demonstration usually suffices to impart all 
its details. As, however, all cannot avail themselves of such 
personal instruction, an attempt is here made to substitute it, 
as well as my descriptive powers will allow. 

Anterior Urethroscopy. — 1. Have the patient lie on an oper- 
ating-table, or sit on a high chair. The former is always pref- 
erable, especially when an intra-urethral operation is to be per- 
formed or when remedies are to be applied. When a chair is used 
the patient should sit as far forward as possible upon its front 
edge, its back supporting his shoulders, and his legs wide apart. 

2. Cleanse the foreskin, glans, and meatus thoroughly with 
absorbent cotton soaked in bichloride 1 : 6,000. 

3. Select the urethroscopic tube that will readily pass the 
meatus. Those experienced in urethroscopy will have no diffi- 
culty in doing this. The novice will do well to employ a Piffard 
meatometer, which often reveals that a meatus which appears to 
be very tight is rapidly, painlessly extensible so that it will 
offer no resistance to a very large tube. On the other hand, it 
will often show that quite a large meatus is no guide to a very 
tight posterior boundary of the fossa navicularis. In the latter 
case, a much smaller tube must be used or a preliminary deep 
meatotomy performed. 

4. After cleansing the tube and obturator, pass each one 
separately through the flame of an alcohol lamp or Bunsen 
burner. Then insert the obturator into the tube and pour gly- 
cerin upon them until the tube, and especially the projecting 
tip of the obturator, is thoroughly lubricated. 

5. Take the penis in the left hand as for anterior irrigations 
and wipe upon the meatus some of the excess of the glycerin 
from the tube in the same manner as was recommended before 
(insertion of a dilator, vide page 153). 

6. Insert the tube gently, without any gyrating motions, 
until it is arrested by the compressor urethrse or the anterior 
layer of the triangular ligament. If it does not proceed so far 
without the employment of force, stricture or some other abnor- 
mality obstructs its progress. Then a smaller tube must be 
used. Only exceptionally is there any practical value in em- 
ploying a tube smaller than a 24 F., save by urethroscopic ex- 
perts. A tube so large as to give pain or to produce excessive 
bleeding thwarts the purposes of urethroscopy. 

13 



194 THE IRRIGATION TREATMENT OF GONORRHOEA. 

7. Withdraw the obturator, after giving it a slight turn in 
either direction. 

8. Dry the urethra of excessive secretions by gently mop- 
ping it through the tube by means of applicators wrapped with 
absorbent cotton. Uncut match sticks will be found most con- 
venient for this purpose. 

9. Insert the light-carrier, and fasten it to the spur on the 
disc. 

10. Attach the megaloscope when required. 

11. Draw the tube slowly out of the urethra. As this is 
being done all its parts fall into view. When one requiring 
special investigation or treatment is met, bend the penis over 
the tip of the tube in the direction opposite to the side at which 
the point to be examined appears. This stretches the mucosa 
at such a point for better examination or treatment. The fourth 
or fifth finger of the left hand holding the penis can push the 
urethra still further into view. 

12. As an additional safeguard, it is well to irrigate the an- 
terior urethra after a urethroscopy, as after any other instru- 
mentation. 

Posterior Urethroscopy. — (a) Place the patient in the posi- 
tion for perineal section. 

(b) Perform the steps indicated above (1 to 6). When the 
tip has reached the compressor make gentle pressure against it; 
at the same time depress the tube between the thighs. Then, 
watching for the end of an expiration, gently thrust the tube 
inward and slightly upward. Usually the grasp of the com- 
pressor is felt upon the tube for an instant ; immediately there- 
after it can be drawn forward and backward. This should not 
be done bruskly lest the tip injure the very sensitive posterior 
urethra. 

(c) Withdraw the obturator. This is usually followed by 
some urine. 

(d) Dry the posterior urethra as much as possible with ab- 
sorbent cotton wrapped about applicators, taking more care than 
ever to use no violence. A little blood upon the cotton is, how- 
ever, not unusual. 

(e) Insert the light-carrier. Even if urine trickles into the 
posterior urethra and out through the urethroscope, it will not 
extinguish the light, as it would were an uncovered, incandescent 



URETHROSCOPY. 195 

wire employed. The posterior urethra can consequently be 
most deliberately examined, its secretions mopped up, and ap- 
plications made under the guidance of sight. 

An intravesical irrigation of potassium permanganate 
1:6,000, or of boric acid four percent., should be used after 
posterior urethroscopy. 

Urethroscopic Diagnosis. — The recognition of urethral dis- 
turbances, like a knowledge of the urethra in health, cannot be 
acquired, except most laboriously, from mere descriptions. Even 
such graphic details as those furnished by Oberlaender, Koll- 
mann, and Wossidlo are of use only to the urethroscopist 
whose eye has received some training. They then are invalu- 
able. 

Still, those who are prevented from obtaining personal in- 
struction in the urethroscopic appearances are entitled to such 
guidance as is within the writer's power. To this end the fol- 
lowing attempt is made. 

Tlie Urethra in Health. — Even when observing most scrupulous 
asepsis no physician will insert an instrument into a urethra 
which he knows to be in health. But the practitioner may avail 
himself, for the purpose of studying the normal urethra, of a 
class of neurasthenics to whose general condition urethroscopy 
acts as a most grateful placebo. No matter how perfect the 
condition of their urinary channels, nor how firm the physician 
is in assuring them of that fact, they are satisfied and believe 
themselves improved with each urethroscopic examination. 

The study of urethroscopy on cadavers is absolutely useless. 
Circulation having ceased, the natural color and consistence of 
the mucosa are gone and offer no means for comparisons. 

A first glance into the normal urethra shows a red glare, re- 
calling one's initial effort at ophthalmoscopy. After some prac- 
tice one learns to distinguish brilliancy, colors, folds, and striae. 
The normal " central figure," as Oberlaender calls that part of the 
urethra which presents when the tube is held in the exact axis 
of the canal, merits study, as do the mouths of the crypts which 
later on become evident to the investigator. Under the megalo- 
scopic attachment the submucous blood-vessels become visible ; 
their normal or excessive tortuousness should receive heed. 

Even with these premises it will be found that the urethra, 
like other organs, varies exceedingly within the limits of health. 



196 THE IRRIGATION TREATMENT OF GONORRHOEA. 



The Normal Anterior Urethra. 

The normal brilliancy of the urethra varies in its different 
parts. The cavernous portion is so brilliant that it suggests 
disturbing reflexes. The fossa is perhaps almost as brilliant, 
but the paleness of its submucous tissues makes the whiteness 
thereof more apparent. 

The normal color varies considerably. It may be ansemic, 
pale, or light pink; moderately hypersemic, roseate to red; hy- 
persemic, intensely red. 

The normal folds vary with the calibre, thickness, and con- 
sistence of the urethra. A narrow ansemic urethra shows slight 
folds or none at all ; while a wide, thick, coarse urethra contains 
five to eight more or less deep folds of mucosa. 

The normal strim appear as fine yellowish- white marks, radi- 
ating from the central figure upon the eminences of the folds. 
This striation is not found in all urethrse. 

The normal central figure suggests the opening of a rubber 
" spring " tobacco pouch, where the distal end of the tube presses 
against the mucosa by its weight. Ever so slightly drawing 
the penis out gives this region a funnel-like appearance, leaving 
the " central figure " somewhat smaller, and differing in various 
parts of the urethra. Just behind the glans it appears as a 
small round or oval opening, deeper within the urethra it looks 
like a closed dimple, and at the bulb its lower half arches for- 
ward. 

The Morgagnian Crypts.— 'When drawing the tube out of the 
urethra five to ten little shallow depressions fall into view, most 
of them centrally located toward the upper two-thirds of the 
canal. These are the openings of the Morgagnian crypts. 

The megaloscopic attachment will considerably augment the 
apparent size of the above-described parts. 

The Normal Posterior Urethra. 

The caput gallinaginis (veru montanum, collicnlus seminalis) 
is usually first seen in the posterior urethra. It is about the 
size of a split pea, semiglobular in shape, sometimes flattened 
and smooth, sometimes elevated and with a furrowed surface. 
It is of the same red color as the surrounding mucous mem- 



URETHROSCOPY. 197 

brane. Depressions suggesting crypts may sometimes be seen 
about it. These are the openings of the prostatic sinus, and of 
the prostatic and ejaculatory ducts. 

The sinus pocularis (uterus or utriculus masculinus) opens at 
the anterior declivity of the caput gallinaginis as a fine slit. 
It is a little sac, of a lengthened pear shape, which passes up- 
ward and backward to the base of the prostate and ends between 
the ejaculatory ducts. It may be materially enlarged, so much 
so as to catch and arrest the progress of an instrument toward 
the bladder, if the instrument is not guided along the roof of the 
posterior urethra. 

The posterior urethral funnel is very short. 

The lustre of the posterior urethral mucosa is less than that 
lining the anterior urethra. 

The posterior urethral folds are so shallow as often to convey 
the impression of their entire obliteration. 

The anterior boundary of the posterior urethra is naturally the 
posterior boundary of the anterior urethra. The withdrawal of 
the tube marks it clearly, not only by release from the tight grasp 
of the compressor upon the tube, but also by the appearance 
of the marked folds of the bulbous portion. 

Bleeding during posterior urethroscopy is not at all infre- 
quent,^ especially when it is made for the first time. 

Urethroscope Appearances. 

For the student's convenience, the appearances of the ure- 
thra are here alphabetically arranged. No pretence to any- 
thing more than a mere introduction to the study of urethro- 
scope diagnosis is made. 

Bleeding in the posterior urethra occurs more readily than in 
health from mere contact with the tube in the soft infiltration of 
chronic posterior urethritis. 

Bleeding Spots. — Where epithelial denudations have been 
followed by slight granulations, these bleed easily. 

Blood-vessels not visible in hard infiltrations. 

Brilliancy (see Lustre). 

Caput gallinaginis pale, yellowish color, lacks lustre, does 
not project, is not wrinkled, but is flat and smooth in hard in- 
filtration of the posterior urethra. 



198 THE IRRIGATION TREATMENT OF GONORRHCEA. 

Central figure appears as a wide, often distorted passage in 
hard (dry) infiltrations. 

Color, dull gray in hard infiltrations. 

Cyanotic, purplish color of posterior urethra evidences soft 
infiltration. 

Denudation, epithelial, in advanced inflammatory processes 
and in superficial traumatisms of the mucosa. 

Desquamation, epithelial, distinct, in hard infiltrations. 

Desquamation, epithelial, slight, in somewhat advanced in- 
flammation. 

Dull, dry epithelium with lack-lustre appearance, indicates 
subepithelial inflammation of the glands. Their orifices are 
then not visible. 

Dull, uneven mucosa, when in the first stage of inflammation 
the cellular infiltration is denser than ordinarily. 

Epithelial denudation, in advanced inflammatory processes. 

Epithelium desquamating (see Desquamation, epithelial, dis- 
tinct and slight). 

Folds absent in hard, dry infiltrations. 

Folds grosser, thicker, coarser, broader and from four to 
six in number instead of from eight to twelve, in more dense 
cellular infitration than usual in the early stage of inflamma- 
tion. 

Gaping Glands. — The orifices of Littre's glands and of the 
Morgagnian crypts gape and are surrounded by a puffy, red, 
prominent wall, forming a distinct boundary from the healthy 
tissues, in the more severe forms of chronic gonorrhoea, with 
consequent infiltration around the crypts. Occasionally some 
secretion oozes from the orifices in this stage of urethritis 
mucosae or soft infiltration. 

Glands and crypts are always visible in first degree of hard 
infiltration as red inflamed spots. 

Glands and crypts are not visible, or but very few appear, in 
the second variety of infiltration (dry infiltration), as their 
orifices are covered by epithelia and connective tissue. 

Glandular Orifices. — More are visible than in health, when 
the mucosa is diseased. When the epithelial layer of the mu- 
cosa is destroyed, then the more deeply the mucosa is invaded, 
the greater is the exposed part of the glands. They appear 
as minute red specks, mostly in groups. When the megalo- 



URETHROSCOPY. 199 

scope is used, the glandular form and ducts are made plainly 
visible. 

Granulations appear on spots that have been denuded of 
their epithelium. They often bleed readily at contact with the 
margin of the tube. 

Gray Color. — In hard, dry infiltrations the mucosa has a 
gray color. 

Grayish opaque veil covers mucosa in hard infiltrations. 

Hard infiltration is rare in the posterior urethra. 

Hard infiltration is the outcome of transformation of cellular 
into fibrous infiltration. Its urethroscopic manifestations nat- 
urally vary as this transformation progresses. 

Hillocky mucosa is sometimes seen in hard infiltrations. 
The mucosa has lost its brilliancy and may distinctly des- 
quamate. 

Infiltration, hard, rare in posterior urethra. 

Infiltration, soft, frequent in chronic posterior urethritis. 

Littre's glands are grouped about the Morgagnian crypts. 
They are ordinarily not visible in health. The experienced 
urethroscopist, however, employing the megaloscope, in many 
cases can see the mouths of the normal Littre's glands and even 
part of their ducts as they descend beneath the epithelium of 
the mucosa. The mouths of these glands may remain visible a 
long time after the urethra has returned to health. They may 
also be invisible in disease, if the pathological process occurs 
subepithelially. The form of disease affecting these glands, 
whether visible or not, shows its results upon the Morgagnian 
crypts. 

Small red points are the mouths of Littre's glands in simple 
swelling. 

Large red points, projecting into the urethra, show that 
Littre's glands are in a state of infiltrative inflammation. The 
fibrillary connective tissue, always present in chronic gonor- 
rhoea, is then formed about the ducts and bodies of Littre's 
glands. This fibrillary connective tissue is caused by the finely 
granular infiltration of the acute inflammation. 

Littre's glands are not visible in the dry form of hard infiltra- 
tions. In this condition the epithelium looks dull (lack-lustre) 
and dry, and desquamates in spots. 

Lustre apparently increased by liquid (glycerin, cocaine, 



200 THE IRRIGATION TREATMENT OF GONORRHOEA. 

mucus, urine) left on mucous lining. To prevent error, the 
surgeon should attempt to remove the excessive lustre by care- 
ful use of absorbent cotton attached to applicators. 

Lustre decreased with increased infiltration and in epithelial 
desquamation, with or without infiltration. The brilliancy is 
entirely lost in hard infiltrations. 

Lustre gone in epithelium covering glandular orifices, with 
dull, dry appearance of mucosa, indicates subepithelial inflam- 
mation of the glands. 

Lustre increased in subacute superficial urethritis. The mu- 
cosa is congested and swollen from cellular infiltration. 

Lustre of posterior urethra increased in soft infiltration. 

The Morgagnian crypts are visible in all chronic diseases of 
the urethra, and are modified according to the intensity of the 
disease of Littre's glands. The mouth of a crypt is larger than 
those of the surrounding Littre's glands, often appearing as a 
quite evident dark-red slit. The variations from simple swell- 
ing to infiltrative inflammation are similar to those which take 
place in Littre's glands. When the megaloscope is used, and 
slight pressure made upon an opening of a crypt by bending 
the urethra, pus may be seen welling from the red slit. Its 
patency ("gaping") will then become more evident and show 
that it is not a tear in the urethra, but really a widely open 
emunctory duct. 

Neoplasms. — The most frequent tumors of the urethra are 
papillomata and fibrous polypi. Carcinoma of the urethra is 
very rare. Before Oberlaender diagnosed a primary carcinoma 
of the urethra in 1893, the disease was only accidentally dis- 
covered in its advanced stages during an operation. Ober- 
laender 's early discovery of this carcinoma enabled the patient 
to be operated upon promptly. A year later no evidence of the 
disease had recurred. 

Opaque grayish veil covers mucosa in severer forms of in- 
filtration. 

Posterior urethroscopy is not permissible in acute or sub- 
acute posterior urethritis, in tuberculosis, or in acute prosta- 
titis. 

Prominence, reddish, within the mucosa, with a central 
dimple and invisible lumen, is seen when the 'inflammation has 
become follicular. The finger can feel these encapsulated crypts 



URETHROSCOPY. 201 

as small hard nodules. Their breaking down may produce 
peri-urethral abscess. 

Psoriasis mucosce iirethralis (Oberlaender) — see White Patches. 

Purple color, of posterior urethra — see Cyanotic Color. 

Red specks with swollen, puffy surroundings, occasionally 
exuding a watery, milky, or purulent discharge, show in- 
flammation of the Morgagnian crypts. See also Glandular 
Orifices. 

Resistance to urethroscopic tube as it is being introduced is 
felt in hard infiltrations. 

Rigid Urethra. — The denser the fibrous tissue in dry, hard 
infiltration, the more rigid does the urethra become ; in its fully 
developed form it shows white cicatricial tissue, spotted witli 
groups of red orifices of Littre's glands. 

Scaly and uneven epithelial layer in severe infiltrations. 

Smoothness of epithelium lost in severer forms of infiltration 
of the mucosa. 

Specks, red — see Glandular Orifices. 

Specks, white— see White Patches. 

Stria y , almost or quite obliterated in dense cellular infiltra- 
tions ; no vestige of them remains in hard, dry infiltration. In 
some normal urethrse the stria3 are absent. 

Swelling of mucosa of posterior urethra in soft infiltration. 

Transparency lost in hard infiltrations. 

Tumors — see Neoplasms. 

Ulcerations due to epithelial denudations of inflammatory 
origin are usually longitudinal. They may result from trauma- 
tism produced by excessive or violent dilatation. Ulceration of 
a circular tendency may be chancre or chancroid. 

Uneven and dull mucosa in denser cellular infiltration, at the 
first stage of inflammation. 

Uneven and scaly epithelial layer, in severe infiltration. 

Veil,— A thin veil seems to cover the urethra in hard infiltra- 
tion ; in spots elevated scales present. These gradually heal. 

White patches, irregular in shape from small specks to large 
patches, called "psoriasis mucosae urethralis " by Oberlaender. 
Kollmann found these psoriatic pellicles to consist of cumuli of 
firmly agglutinated epithelial cells, whose nuclei stained dis- 
tinctly with Bismarck brown. These epithelia were of polygonal 
pavement shape, rounded epithelia, and some high cylindrical 



202 



THE IRRIGATION TREATMENT OF GONORRHOEA. 



epithelia as are found in the prostate. The course of this 
psoriasis is very chronic. 

Note : This chapter is elaborated from the report of my first 
public demonstration, in the Journal of Cutaneous and Genito- 
urinary Diseases for April, 1899, and from my article in the 
Journal of the American Medical Association for September 7th, 
1899. 



XIV. THE PROOFS OF^ CURE OF GONORRHOEA. 

To secure a patient who no longer presents any tangible 
evidences of gonorrhoea against auto-reinfection and possible 
infection of others, no case should be dismissed from treatment 
until all the tests at present known have resulted negatively in 
his case. 




Fig. 57.— Stripping TJretnra. 

While most of these have been mentioned incidental to 
other matters, all are here placed together for the practitioner's 
convenience. In describing them, a note is added to each test 
of the errors that may thwart its purpose. 

Stripping the Urethra. — Patients, especially those anxious to 



THE PROOFS OF CURE OF GONORRHOEA. 203 

demonstrate that they have recovered, squeeze the penis, some- 
times quite violently, to prove the absence of a discharge. The 
conformation of the organ renders this method futile in bring- 
ing to view any evidence of disease, even when the urethra has 
an appreciable quantity that can be produced with the proper 
technique, as follows : 

1. Best the four left fingers upon the outer side of the left 
corpus cavernosum, and the left thumb upon the opposite side, 
thus endeavoring to approximate the corpora cavernosa to each 
other and exercising a pressure, as if to squeeze the urethra 
from between them. 

2. With the bent right index finger press the peno-scrotal 
angle backward as far as possible to the lower margin of the 
pubic arch. Firmly pressing the so bent finger upward and 
carrying this pressure steadily forward, any moisture thus ob- 
tainable will be brought to the meatus. It is not at all rare that 
a large yellow, purulent drop replete with gonococci can be so 
stripped from the urethra long after all discharge has ceased. 

A great many patients, as anxious as the first mentioned, 
but in the opposite direction — namely, to prove that they are not 
cured — acquire remarkable dexterity in maintaining an urethror- 
rhcea by frequent strippings of the urethra. These can, at al- 
most all times, produce a transparent or translucent drop at the 
meatus. Its microscopical examination reveals mucus, urethral 
epithelia, and occasionally some leucocytes. 

In either case, urethroscopic examination is required to de- 
termine the region or gland whence the drop comes, or to elicit, 
in the second category of cases, whether the drop the patient 
milks from his urethra is due to general excessive juiciness of 
the canal. In the former the treatment mentioned in Chapter 
IX. is applicable. But a patient who maintains the irritability 
of his urethra by continual milkings is more difficult to manage. 
Arguments and persuasion are ordinarily of little avail; the 
conviction that he is incurable is usually deep-rooted in his 
mind, and is reinforced by each milking, wherein he persists 
until the convincing drop is brought forth. A good method for 
the treatment of such cases is to irrigate the urethra with four- 
per-cent. boric-acid solution and to order the patient, with a view 
to diverting his attention from persistent milkings, to inject a 
drachm or two of the same solution several times daily, if he 



204 THE IRRIGATION TREATMENT OF GONORRHOEA. 

cannot be otherwise dissuaded from the milking habit. One 
case, after all else had failed, was cured by the cruelty of paint- 
ing the lower half of his penis with cantharidal collodion. The re- 
sultant blisters prevented his handling the organ for two weeks ; 
then they were permitted to heal. He did not resume the milk- 
ings, but persists in the firm belief that the blistering cured him. 

Possible Errors. — Stripping the urethra may fail to produce a 
drop or an excess of moisture from a diseased anterior urethra, if 
the patient has urinated within a few hours. In many cases it can- 
not be made evident at all, unless the examination is made in the 
morning, if the patient has not urinated since the night before. 

If the drop cannot be stripped out during the day, and if for 
any reason the patient cannot be examined while his bladder 
holds the night's urine, the patient should be given several 
cover-glasses and be instructed to catch a small quantity of the 
morning drop upon one and press another cover-glass upon it. 
Thus the drop can be brought to the office for microscopical ex- 
| amination. The fact that one specimen is found to be free from 
1 gonococci does not prove their absence. It will always be best 
to make ten such examinations, two or three days apart, before 
finally concluding that the morning drop contains no bacteria. 
Even then it is by no means safe to declare the patient unable 
to infect others or to reinfect himself. Gonococci may be resid- 
ual in some part of the urethra, and by their presence pro- 
voke the non-bacterial drop. Therefore this test cannot be 
accepted as final, nor can the case be pronounced cured, until 
all the tests here recited have proven the absence of gonococci 
and the healthy condition of the urethra and its adnexa. 

The Urine. — Whenever possible, examination of the urine 
for evidences of urethral disease should be made before the 
patient has passed any part of his night's accumulation in the 
bladder. Ordinarily 1 it is assumed that the first 50 c.c. passed 
in the morning suffice to wash out the anterior urethra. This 
quantity, however, does not seem sufficient in all cases. There- 
fore it is best always to have the patient pass first 150 c.c. into a 
tube as directed (on page 25) in Chapter IV. , and to pursue the 
other steps there directed. 

Possible Errors. — On centrifuging clear urine, a deposit may 

'Posner: Diagnostik der Harnkrankheiten, Berlin, 1895. 



THE PROOFS OF CURE OF GONORRHCEA. 205 

be obtained. If not, a few drops of alcohol added to the speci- 
men will, on second centrifuging, throw down a slight deposit. 
In case this deposit, microscopically examined, shows thinned 
epithelium with very faint nuclei or none, the patient should 
be warned that an infiltration is at least beginning, and that he 
must be at once treated by dilatations lest he become a victim 
of stricture and all it portends. 

Filaments, flakes, etc., have been discussed in other parts of 
this book (see page 144). 

Ramonage. — The great master Guy on suggests this method 
of obtaining specimens from the deeper urethra for microscopic 
examinations. It consists in anointing with glycerin as large a 
bougie-a-boule as can be easily introduced. Immediately upon 
its withdrawal from the urethra, the substances that adhere, 
especially to its shoulder, are removed for examination. 

This bougie may, however, fail to bring with it any patho- 
logical products. Owing to a possible excess of glycerin or an 
over-juicy urethra, evidences of disease may be swept from the 
bougie before it is entirely withdrawn. Still, in the majority 
of cases it will be well to examine the substances adhering to 
the bougie, even when the purpose of its use was only to search 
for infiltrations, stricture, etc. 

Scraping the urethra is performed by holding a platinum 
loop in the alcohol or Bunsen flame until it is red hot, and, 
while not permitting its sterility so obtained to be impaired 
by contact with anything, to allow it to cool. Then, holding 
the penis as for stripping (vide Fig. 57) the cooled loop is gently 
passed into the urethra. As it is drawn out it is pressed against 
the urethral walls sufficiently to detach some of the adherent 
contents. They will at least fill the eye of the loop. Striking 
it upon a slide or upon a cover-glass furnishes a specimen for 
microscopical examination. 

After each such scraping the loop must be thoroughly re- 
sterilized by flaming, lest by it the next case so examined be in- 
fected, or, at least, the specimen taken from him be vitiated. 

Swabbing the Urethra. — When the urethral excess is too 
minute to be obtained by ramonage or scraping, sufficient moist- 
ure can be swabbed therefrom for examination. The swab is 
made by tightly wrapping a small quantity of borated cotton 
upon a sterilized platinum loop ; then lighting the cotton in the 



206 THE IRRIGATION" TREATMENT OF GONORRHOEA 

flame and instantly blowing it out. A light rap with the handle 
of the loop upon a finger will cause the charred parts of the 
cotton to drop off. This swab may then be used without a 
lubricant to obtain a specimen. Its employment is naturally 
limited to the anterior third or half of the urethra. 

Residual Posterior Gonorrhoea — see Chapters IV., VIII., 
and X. 

Expression Urine. — The patient is laid upon a table and the 
index finger, prepared as directed in Chapter XI., is well an- 
ointed and inserted into the rectum. Avoiding the prostate, 
the pulp of the finger presses upon the posterior urethra by 
stroking it firmly from above downward against the pubis. 
The urine accumulating during this process will contain as 
much evidence of posterior urethral disease as can be detached 
by this method. 

Infection of the Prostate, Seminal Vesicles, or Cowper's Glands. 
— Stripping these adnexafor the purpose of obtaining specimens 
therefrom is described in Chapter XI. 

Possible Errors. — No attempt should be made to obtain speci- 
mens from the posterior urethra or the prostate, seminal vesi- 
cles, or Cowper's glands, at the same examination, lest their 
contents intermingle in the urethra and thus give no positive 
indications regarding the region infected. 

Beer Test. — A week after all evidence of gonorrhoea has 
ceased the patient is ordered to drink, in the evening, double 
the quantity of beer or champagne he was in the habit of con- 
suming before they were forbidden him. This may, within 
twelve to thirty-six hours, produce a discharge, if any disturb- 
ance exists. Microscopical examination of the discharge will 
decide its character. 

Silver and Bichloride Tests. — When the beer- test fails to pro- 
duce a discharge, an irritant irrigation of the anterior urethra 
with silver nitrate one per cent, or corrosive sublimate 1:5,000 
will evoke one, lasting from eight to thirty-six hours. If the 
discharge so established contains gonococci, they most probably 
but not positively are located in the anterior urethra. 

Condom Test. — The other tests having resulted negatively, 
the patient is advised to use a condom at his next sexual inter- 
course and to bring it with its contents for microscopical ex- 
amination. It is most likely to contain, in addition to semen, 



THE PROOFS OF CURE OF GONORRHOEA. 20T 

some of the contents of the urethral mucosa and its glands, as 
well as any bacteria the reproductive apparatus may harbor. 
The various local tests suggested must then be employed to de- 
termine the region in which the bacteria are held. 

It would go beyond the province of this effort to discuss the 
morality of advising a patient to cohabit or to use a condom. 
The majority during the acuity of their sufferings invariably 
forswear sexual relations during the remainder of their lives. 
As a rule, the more vehement their asseverations in this regard 
the sooner will they again seek sexual gratification, often during 
the period when it is still positively forbidden. With or with- 
out permission, when evidences of the disease have passed and 
the tests before mentioned have yielded negative results, these 
patients will have coitus. Is it not best to avail one's self of their 
immorality for their own good and the protection of their pro- 
spective wives by asking for a condom specimen? 

When even the condom test has proven negative or when the 
physician's conscientious scruples cause its omission the final 
resort is 

Tlie Urethroscope (see Chapter XIII.). — If a healthy urethra, 
is found, and its adnexa are proven to be normal, the case may 
be discharged. 

Preparation of a Specimen for Microscopical Examination. — 
For the convenience of those not rendered familiar with the tech- 
nique, by daily examination for gonococci, the method that is 
easiest and most reliable is here recapitulated : 

1. Spread as thinly as possible upon a cleaned cover-glass 
the discharge, drop, filament, urinary sediment, or specimen 
taken with a sterilized platinum needle from the contents of a 
condom. 

2. Let the specimen dry under a bell-glass, to protect it 
from dust or air microbes. This usually requires about three 
minutes. 

3. Pass it three times through the opened Bunsen flame, 
with an even motion, to " fix " it. 

4. Drop eosin (saturated solution in alcohol) upon the cover- 
glass and hold it over the closed Bunsen jet until a slight, 
visible evaporation results. 

5. Hold it under a stream of water until all the eosin that 
can be washed away is carried off. If the cover-glass stood on 



208 THE IRRIGATION TREATMENT OF GONORRHOEA. 

edge over filter paper gives the paper ever so slight a tinge, the 
washing has been insufficient, and must be repeated until noth- 
ing but clear water comes from the glass. 

6. Drop two per cent, methylene blue upon the glass and let 
it rest there, covered, for five minutes. 

7. Wash as described under 5, let it dry, and then mount it 
for examination. 

8. Unstain by the Gram method. 

Physicians who cannot devote the ten or twelve minutes to 
this preparation of a slide will do well merely to take the speci- 
men on a cover-glass, place another cover-glass upon it, and 
send the specimen to a colleague or a bacteriological laboratory 
for examination. 

For positive assurance culture experiments are necessary. 
These, however, cannot be made save by a physician provided 
with a laboratory fitted for the purpose. 



XV. THE MARRIAGE OF GONORRHCEICS. 

The question that most frequently confronts the general 
practitioner, as well as the specialist, concerns the marriage of 
those who have had gonorrhoea, and the resumption of matri- 
monial relations by married infractors who acquired the disease 
extra domo. 

Advice in this regard cannot be lightly given. In support 
hereof a slight historical digression may be permitted. 

E. Noeggerath, 1 of New York, in 1872 asserted, as Ricord 
had before him, that eight hundred men of every one thousand 
living in large cities had gonorrhoea. The recently deceased 
eminent gynecological surgeon, Mr. Lawson Tait, went further 
in this, claiming that every man at least once during his life 
acquired clap. While observation and experience compel ac- 
ceptance of Tait's estimate as nearer the facts, the author can 
positively assert that at least one man, now almost fifty years 
of age, has not been so unfortunate. 

Noeggerath, in the same dissertation, and in the light of 
the treatment then employed, asserted that men infected with 

1 Noeggerath : Die latente Gonorrhoe irn weiblichen Geschlecht, Bonn, 
1872. 



THE MARRIAGE OF GONORRHCEICS. 209 

gonorrhoea never recovered. He further insisted that ninety per 
cent, of these men, when they married, infected their wives. 
The eminent surgeon's views were fiercely combated, yet 
stanch in his convictions he, four years later, summarized his 
conclusions in a paper on the subject, 1 as follows: 

"1. Gonorrhoea in the male, as well as in the female, per- 
sists for life in certain sections of the organs of generation, not- 
withstanding its apparent cure in a great many instances. 

"2. There is a form of gonorrhoea, which may be called 
latent gonorrhoea, in the male as well as in the female. 

" 3. Latent gonorrhoea in the male, as well as in the female, 
may infect a healthy person either with acute gonorrhoea or 
gleet. 

" 4. Latent gonorrhoea in the female, either the consequence 
of an acute gonorrhoeal invasion or not, if it pass from the latent 
into the apparent condition, manifests itself as acute, chronic, 
recurrent perimetritis or ovaritis, or as catarrh of certain sections 
of the genital organs. 

"5. Latent gonorrhoea, on becoming apparent in the male, 
does so by attack of gleet or epididymitis. 

" 6. About ninety per cent, of sterile women are married to 
husbands who have suffered from gonorrhoea, either previous to 
or during married life." 

Noeggerath's conclusions were based purely upon clinical 
experience. They were in no wise essentially controverted 
Avhen three years later Neisser 2 published his epoch-making 
discovery of the gonococcus. 

If Noeggerath's note of alarm needs further confirmation it 
is found in the statistics of the German empire for 1894. These 
show that of the women who died of diseases of the womb, or 
of its adnexa, eighty per cent, were proven to have succumbed 
to gonorrhoeal infection. They further show that of all chil- 
dren who became hopelessly blind after having been born with 
healthy eyes, eighty per cent, went into a life of darkness from 
gonorrhoea. Since 1894, the Crede method of swabbing the 
eyes of the new-born with two-per-cent. silver-nitrate solution 

1 Noeggerath : "Latent Gonorrhoea in the Female." Transactions of the 
American Gynecological Society, 1876. 

2 Neisser: "Eine der Gonorrhoe eigenthiimliche Mikrokokkenform." 
Centralblatt fiir medicinische Wissenschaften, No. 28, 1879. 

14 



210 THE IRRIGATION TREATMENT OF GONORRHOEA. 

has saved many eyes. And since the irrigation treatment and 
a clearer understanding of the dangers of gonorrhoea have be- 
come more generalized, doubtless many women are saved from 
infection. 

It cannot for a moment be assumed that the men who caused 
the death of their wives or the blindness of their children mar- 
ried with the knowledge that they could produce such disastrous 
results. If there is one among the thousands who did so, no 
punishment known to any modern criminal code could ade- 
quately expiate his iniquity. With the ever-increasing atten- 
tion given by the profession to the appreciation of the dangers 
of gonorrhoea, it is to be hoped that this menace to human hap- 
piness will be eventually stamped out. 

It is perfectly true that many men to-day, uninformed of the 
seriousness of clap, boast of having had innumerable attacks of 
the disease and of having relieved themselves therefrom by 
trifling medication or advertised nostrums. It is exceedingly 
interesting to note that none of these boasts are made while the 
patient has gonorrhoea, and that he does not employ the vaunted 
preparations when he acquires a new attack. 

The physicians and those of the public who make clap a 
subject of witticism are not without their influence upon the 
people in general. All men, however, when they have gonor- 
rhoea, know that it was contracted from a woman, and it would 
be the extreme of pessimism to assert that a man, knowing that 
he can infect a woman, would marry. Still, it is difficult to 
convince such a man, after he perceives no evidence of the dis- 
ease, that the danger of infecting his future wife may continue. 
For such it will be well to cite a typical case, couched in lan- 
guage within the reach of his intelligence. 

Five, ten, or more years after a man had gonorrhoea, time 
has almost if not entirely effaced the disagreeable incident from 
his recollection. He marries a girl, strong and healthy. The 
young wife soon begins to fade. Yague pains set in. If her 
friends love her, she will be twitted with advice and congratula- 
tions regarding the presumed coming maternity. Her form, 
too, suggests such possibility. But by the time, or before, the 
child that is to make her still more loved by her husband is ex- 
pected, it is found necessary to seek professional advice. 

A cyst of the ovary, a Fallopian tube filled with pus, or 



THE MARRIAGE OF GONORRHCEICS. 211 

some other dangerous disease is discovered. An operation, 
perilous to life, must be performed to save her. If she survive, 
she will no longer be a woman, for she cannot become a mother. 
The light of modern microscopy brought to bear upon the 
tumor, cyst, or other substance removed reveals gonococci. 
Eemember that this wreck, but a few short months ago a vigor- 
ous, healthy girl, was "as chaste as ice, as pure as snow." 
Remember, too, that, her husband presented no sensory evidence 
of the disease that killed his cherished wife. Killed — the word 
is advisedly employed — for, though she live, she is worse than 
dead; she is not only unsexed, but also physically and often 
mentally destroyed. 

If a patient is morally so debased that such an argument 
does not appeal to him, he should be made to understand what 
at least some of the complications and sequelae of gonorrhoea 
portend to him. He will listen to the fact that gonorrhceal pus 
in ever so minute a quantity entering the conjunctivae can irre- 
mediably destroy his sight within twenty-four hours. Equally 
will he appreciate that his testicles can be invaded, rendering 
him impotent to further disseminate the disease. Little as he 
may care for the lives of others, he can be made to understand 
that even long after he observes any evidence of disease, he may 
die from the consequences of gonorrhoea. 

All these facts, impressed upon such a man, will induce him 
to submit to the tests that will prove whether he is cured (Chap- 
ter XIV. ) and to seek treatment for the ailment, if it is discov- 
ered that he still carries the death-dealing microbes. 

Ignorance of the dangers of gonorrhoea is not limited to the 
mentally uncultured. The highest literary universities in our 
land do not teach their students even the veriest rudiments of 
genital physiology and pathology. The editor of one of our 
foremost American magazines, a man of wide general scientific 
attainments, expressed surprise when informed of the origin, 
prevalence, and dangers of gonorrhoea. 

The task of instructing and warning the public regarding 
the dangers of this ever-prevalent disease is left almost wholly 
to the medical profession. But such teaching can appeal only 
to those whose intelligence is of a grade sufficient to grasp its 
importance. Others can be reached only by the law. 

All honor must be tributed to the legislators of Michigan, 



212 THE IRRIGATION TREATMENT OF GONORRHOEA. 

who in their session of 1899 * enacted that : " Any person who 
has been afflicted with syphilis or gonorrhoea, and has not been 
cured of the same, who shall marry shall be deemed guilty of a 
felony, and upon conviction thereof in any court of competent 
jurisdiction shall be punished by a fine of not less than five 
hundred dollars or more than one thousand dollars, or by im- 
prisonment in the state's prison at Jackson not more than five 
years, or by both such fine and imprisonment in the discretion 
of the court." 

While an adulterer or anadultress might by perjury succeed 
in throwing the odium of this law upon an innocent party, the 
fact remains that Michigan stands in the front of the world in 
recognizing the dangers of uncured syphilis and gonorrhoea. 
Naturally this enactment must have been prompted by the phy- 
sicians of that State ; therefore the credit thereof belongs to our 
colleagues. But medical men are accustomed and satisfied to 
see the glory of their public work go to others, when humanity 
at large and individuals are benefited and protected thereby. 

1 Michigan Monthly Bulletin of Vital Statistics, June, 1899. 



This little book has been written to place before those phy- 
sicians who may not be thoroughly familiar therewith — 

1. The rationale and technique of irrigations in acute gon- 
orrhoea. 

2. The advantages of dilatations and irrigations in chronic 
gonorrhoea. 

3. The dangers of uncured gonorrhoea, and the means of 
locating the foci of the disease, especially after its external 
manifestations have subsided. 

4. To urge physicians to use their influence for the dissem- 
ination of a better understanding of the disease. 

If in but one instance these purposes are accomplished, my 
efforts to that end will be amply rewarded. 



INDEX. 



Abortion of acute manifestations, 11 

Abscess, follicular and peri-urethral, 
38 

Absence of gonococci from one speci- 
men not conclusive, 130, 137, 
207 
or reduction of sensation on ejac- 
ulation, 128 

Accessory treatment, 34 

Action of potassium permanganate, 8 

Acute anterior gonorrhoea, 8 

anterior gonorrhoea alone, rare, 8 
posterior gonorrhoea, 19 

Adenitis, gonorrhceal, see Lymphade- 
nitis 

Adhesions, preputial, 41, 88, 90 

Adnexa invaded from posterior ure- 
thral infection, 21 

Agglutination of the meatus, 136 

Albarran instillator, 28 

Albuminuria, 42 ; in posterior gonor- 
rhoea, 22 

Alcohol, 36 

Amusements aid in opposing neuro- 
ses from gonorrhoea, 34 

Ansemia, 42 

Anaesthesia of urethra not necessary 
in irrigations, 18 

Anaesthetizing urethra, 109 

Anterior irrigations, 12; technique 
of, 14 

Antinosin in inguinal adenitis, 81 

Antrophors, 20 

Anuclear epithelium in urine evi- 
dencing infiltration of urethra, 205 

Apparent immunity from gonorrhoea, 
187, 208 

Artificial oedema produced by irri- 
gations, 11 



Artificial prolongation of coitus, 129 

urethritis induced to ascertain 

presence of gonococci, 137, 206 

Asepsis of shield and nozzles, 14 
of urethra, 108 

Aspermia, apparent, 128 

Athletics, 37 

Auto-reinfection in gonorrhoea, 170 

Avoidance of carrying infections to 
patients by the irrigator, 7 

Bacteruria, 144 

Balanitis, 42 

Balanoposthitis, 42 

Ballooning urethra, 16 

Bangs' lubricator, 153 

Bartholin's glands a frequent site of 
residual gonorrhoea, 8 

Bathing, 34 

Beard on sexual neurasthenia, 83 

Beck, radiography of arteriosclerosis, 
55 

Bed, 35 

Beer test, 206 

Beer-tripper, 171 

Be"nique sound, 106 

Berg on general gonorrhceal infec- 
tion, 74 

Bergson on ritual circumcision, 117 

Beverages, 35 

Bicycling, 37 

Birch-Hirschfeld on epididymitis, 57 

Bladder-drainage, continued, 111 ; in- 
terrupted, 112 

Bladder, excessively strong solutions 
accidentally entering, 14, 16 
inflammation of, see Cystitis 
in health, immune to gonorrhoea, 
22 



214 



INDEX. 



Bleeding after urination in posterior 
gonorrhoea, 21, 23 
at or after dilatation, 163, 164 
see Hemorrhage 
Blind fistulse, 45 

Blindness from gonorrhoea, 209, 211 
Bloody emissions, 122 
Bougie-a-boule, 205 
Bracket irrigator, 6 
Bubo, see Lymphadenitis 
Buller's dressing in gonorrhceal oph- 
thalmia, 86 
Buschke on skin diseases complicat- 
ing gonorrhoea, 116 

Calculi, urethral, 71 

Carbonated drinks prohibited, 35, 
172 

Carcinoma of urethra, 200 

Care of irrigator, 5 

Casper ointment, in epididymitis, 61, 
65 ; suspensory bandage, 64 

Catheter-fever prevented by irriga- 
tions, 12, 162 

Catheter for washing urethra is repre- 
hensible, 20 

Causes of chronic gonorrhoea, 126 

Caustic potash test for pus in urine, 
11, 144 

Cavernitis, 45 

Centrifuging urine, 204 

Chancre, 47 

Chancroid, 47 

Chocolate-color emissions, 122 

Chordee, 47 

Chronic gonorrhoea, 125 ; treatment 
of, 145 

Circumcision, 91 ; ritual, dangers of 
traumatism by, 117 ; in France not 
permitted except in presence of a 
physician, 118 

Clap-threads, 68, 145 

Cleanliness in irrigations, 13, 17 

Clear urine not a positive evidence 
of health, 144 

Clothing dilator, 151 

Clots following urine, 21 
in urine, 23 



Cocaine before irrigations, not neces- 
sary, 18 

Cohesion of lips of meatus, 136 

Coitus, incomplete, 46 

Collodion to protect finger in rectal 
exploration, 177 

Colombini on general gonorrhceal in- 
fection, 73 

Color of discharge and color of stain, 
142 

Combined rectal and vesical examina- 
tion of the prostate, 180 

Comma filaments as evidence of pros- 
tatic disease, 69 

Complications of gonorrhoea, 38 
of posterior gonorrhoea, 22 

Compressor as a protection to posterior 
urethra, 19 

Condoms, a cause of auto-infection, 
16 

Condom test, 207 

Condylomata, 48 

Congenital strictures, 117 

Constitutional infection, 73 
symptoms of gonorrhoea, 22 
treatment, 34 

Covers for dilators, 151 

Cowperitis, 50 

Cowper's glands, examination of, 183 

Crede" method to protect the new-born 
from gonorrhceal ophthalmia, 209 

Culture experiments, 208 

Cure, proofs of, 202 

Curette for urethral glands, 165 

Cushing on gonorrhceal peritonitis, 76 

Cystitis, 53 

Cystoscopy in enlarged prostate, 181 

Daily examinations necessary, 58, 80 

Dangers of irrigation, 14 

Death from gonorrhoea, 76, 211 

Defecation drop, 129 

Defective irrigation apparatus, 1 
technique, 1 

De Keersmaecker on chronic urethri- 
tis, 19 

Diday on stains from urethral dis- 
charges, 142 



INDEX. 



215 



Dietetic irregularities producing re- 
currences of gonorrhoea, 171 

Digital palpation of the urethral 
adnexa, 173 

Dilatation, contraindications, 164 

Dilatations, amount of, 162 ; forcible 
not permitted, 164; frequency of, 
162 ; length of each, 162 ; not pain- 
ful, 149 ; technique of, 160 

Dilator covers, 151 ; their steriliza- 
tion, 152 

Dilators, manner of holding, 151 

Discharge in chronic gonorrhoea, 130 ; 
increased after dilatation, 162 ; in 
posterior gonorrhoea, 22 

Discharges of gonorrhoeal pus from 
the posterior urethra, 131 

Disturbed digestion in gonorrhoea, 12 

Diverticle, see Urethral diverticulum 

Donne's caustic potash test for pus in 
the urine, 55, 144 

Dressing glans after irrigation, 16 
penis, 113 

Dribbling of semen after coitus, 139 

" Drinking away a clap," 36 

Drop expressible from healthy ure- 
thra, 84 

Duchastelet urinal, 112 

Dynamic influence of instruments in 
the urethra, 149 

Dysuria in posterior gonorrhoea, 24 

Early symptoms of gonorrhoea, 10 

treatment necessary, 11 
Ejaculatio praecox, 139 
Ejaculations of semen, painful, 138 ; 

premature, 139; suppressed, 129 
Electrolysis of infiltrated urethral 

glands, 166 
Electrolytic puncture of infiltrations, 

166 
Emissions, bloody or chocolate color, 
122 ; painful, 138 ; premature, 
139; seminal, 140 
in posterior gonorrhoea, 23 ; from 
irritable posterior urethra, 140 
Englisch on foreign bodies in the 
urethra, 71 



Eosin counter-stain for microscopic 
specimens, 207 

Epididymitis, 55 

Epispadias, 65 

Epithelium in the urine, 66 ; thinned, 
an evidence of stricture, 66 

Erections in posterior gonorrhoea, 23 
painful, 82, 138 

Eucaine before irrigation not neces- 
sary, 18 ; in retention, 109 

Evacuating bladder gradually in re- 
tention, 109, 110 

Excessive moisture at meatus, 132 
sexual desire, 133 

Exercise, 36 

Expressing urethral secretions, 202 

Expression urine, 204 

Extra-genital gonorrhoea, 9 

Eye, gonorrhoeal inflammation of, see 
Ophthalmia 

Failures in irrigation treatment; 
probable causes thereof, 1 

Fainting during irrigation, 14 

Felicke' on irrigations, 1 

Fever, urethral (catheter-fever), obvi- 
ated by irrigations, 12, 162 

Fig-warts, see Condylomata 

Filaments in the urine, 144 

Finger on the frequency of posterior 
invasion, 19; on purpura rheuma- 
tica as a complication of gonor- 
rhoeal processes, 116 ; on urethro- 
cystitis, 53 ; on epididymitis, 56 ; 
on prostatic filaments, 69 

Fistula, urethral, 66 

Flakes in the urine, 144 

Flexible sounds to prepare the urethra 
for dilatations, 149 

Floaters in the urine, 67, 144 

Follicular abscess, 38 

Folliculitis, see Abscess 

von Frisch on examination of the 
prostate, 178 

Food, 37 

Force never permissible in dilatations, 
164 

Foreign bodies in the urethra, 70 



216 



INDEX. 



Foreskin, tight, irrigation of, 15 

Frank on irrigations, 1 

Frenum, short or rigid, 73 

Fricke's method of strapping testicle 
(author's modification), 61 

Fuller on seminal vesiculitis, 119; 
on tuberculosis of the seminal vesi- 
cles, 122 ; on examination of the 
seminal vesicles, 182 

Fulminant type of posterior gonor- 
rhoea, 27 

Funiculi tis, 73 

Fiirbringer on floaters in the urine, 
67 ; on prostatic filaments, 69 ; on 
over-treatment, 167 

Genesic hyperesthesia, 134 

Gentleness essential in dilatations, 149 

German statistics on death and blind- 
ness from gonorrhoea, 209 

Gerson, scrotal elevating strips, 64 

Gin, 38 

Glands, urethral, infiltrated, syringe 
for their injection, 165 ; curette and 
electrolytic needle for their destruc- 
tion, 166 

Glans, dressing, after irrigation, 16 

Gleet, 77 

Goldberg on results of irrigation 
treatment, 1 

Gonococci proliferate by segmenta- 
tion, 10 

Gonococci cidal action of hot water, 
11 

Gonococcus, an anaerobic microbe, 11 

Gonocystitis, 120 

Gonorrhoea and marriage, 208 

bags, a cause for auto-infection, 

17 
recurrence from marital excesses, 
169 

Gonorrhceal ophthalmia, 85, 209 

Gouley on gonocystitis, 120; on in- 
cision through the rectum for ab- 
scess of seminal vesicles, 122 

Gout, 77 

Goutte militaire, 137 

Granules iu the urine, 142 



Guiard on causes of chronicity, 126 ; 
on classification of substances in 
the urine, 144; on floaters in the 
urine, 67 ; on gonorrhoeas that are 
chronic from the inception, 126, 
135, 185; on "little ejaculations," 
132 ; od mechanism of gonorrhceal 
discharge from posterior urethra, 
132 

Guiteras on stricture of meatus, 118 

Gumma of frenum, 39 

Guterbock on prostatic examination, 
178 

Guy on on classification of substances 
in the urine, 144 ; classification of 
urinary filaments, 70; curved pos- 
terior dilator, 158; on discharges 
simulating spermatorrhoea, 131 ; on 
dressing penis, 113 ; on the dynamic 
influence of instruments in the ure- 
thra, 149 ; on foreign bodies about 
glans, 143; on instillations, 29; on 
irrigations, 1 ; on mechanism of 
emission of gonorrhceal discharge 
from posterior urethra, 132 ; modi- 
fication of Mercier catheter, 114 ; 
on normal mucous filament, 68 ; on 
ramonage, 205; retention-catheter, 
111; sound, 106; on "stammering 
urination," 103 

Hematuria in posterior gonorrhoea, 
23 

Hemorrhage, 77 ; ex vacuo, from rap- 
idly emptying the bladder, 110 

Hemospermia, 79, 122 

Hairpin in urethra, 72 

Hatpin in urethra, 72 

Heiman on the gonococcus, 77 

Heitzmann on epithelia in urine, 66 ; 
on filaments, 70; on gonocystitis, 
122 

Hoffmann on examination of the pros- 
tate, 178 

Horand suspensory bandage, 64 

Horowitz on Cowperitis, 50 

Horseback riding, 37 

Hydrocele, 79 



INDEX. 



217 



Hydrogen peroxide not a gonococci- 

cide, 11 
Hyperesthesia, 149 
Hypospadias, 65 

Immunity, apparent, to gonorrhoea, 
187, 208 

Imperious urination in posterior gon- 
orrhoea, 24 

Increase of discharge after dilatation, 
162 

Increasing intervals of treatment to 
test progress of case, 167 

Incrustated meatus, 136 

Indications for irrigations, 12 

Inefficient sounds, 148 

Infection by apparatus, precautions 
against, 13 
from a sound, 9 ; from a water- 
closet, 9 

Infiltration-anaesthesia, see Schleich 

Infusions in posterior gonorrhoea, 27 

Inguinal adenitis, antinosin in, 81 

Instillations of silver nitrate in pos- 
terior gonorrhoea, 29 

Instrumentation of acutely inflamed 
urethra, 20 
of the urethra or bladder, followed 
by irrigations, 12, 162 

Intervals between dilatations, 162; 
between irrigations, 19 

Intravesical irrigations, impediments 
to, 31 ; technique of, 29 

Intromission not necessary for acqui- 
sition of gonorrhoea, 8 

Invasion of organism from posterior 
urethra, 20 

Irrigation in recumbent posture, 14; 
in standing posture, 14 

Irrigation-treatment, statistics of re- 
sults, 1 

Irrigations, conditions in which they 
can exercise no effect, 165 ; cure 
ninety per cent, of gonorrhoeas with- 
in fourteen days, 1 ; indications for, 
12 ; prevent urethral fever, 12, 162 

Irrigator, care of, 6 ; cleansing of, 6 ; 
description of, 2 



Irritative urethritis from treatment of 

healthy urethra, 69, 167 
Itching in urethra, 135 

Jadassohn on posterior gonorrhoea, 
19, 102 

Jamin on discharges simulating sper- 
matorrhoea, 131 

Janet on irrigations, 2, 18 ; solutions 
employed, 125 ; treatment of chron- 
ic gonorrhoea, 146 

Joly on ritual circumcision, 117 

Klotz on the effect of carbonated 
drinks, 36 

Kobner on prevention of catheter fe- 
ver, 28 

Kofmann on urethral hemorrhage, 78 

Kollmann on cavernitis, 46 ; electro- 
lytic needle for the destruction of 
urethral gland, 166 ; four-branched 
anterior dilator, 157 ; four-branched 
posterior dilator, 158; Guyon curve 
antero-posterior dilator, 159; irri- 
gating dilators, 159 ; photographs 
of the urethra, 189 ; on psoriasis 
mucosae urethralis, 201 ; syringe for 
urethral glands, 165 

Laceration of urethra avoided, 150, 

154 
Lacuna magna may arrest instrument, 

150 
Langlebert suspensory bandage, 64 
Latent gonorrhoea, 168 
Leleneff on gonorrhoeal neuroses, 82 
Letzel on posterior gonorrhoea, 102 
Lewis on posterior gonorrhoea, 102 ; 
its frequency, 102; infection 
through the lymphatics, 115 ; semi- 
nal vesiculitis, 119 
"Light attacks " of gonorrhoea, 126 
Limits of dilatation and irrigation, 

165 
Linen, stains on, 131, 142 
"Little ejaculations," 131 
Lbwenfeld on sexual neuroses, 83 
Lowered physical condition predis- 
poses to gonorrhoea, 8 



218 



INDEX. 



Lustgarten and Mannaberg on pseudo- 

gonococci, 123 
Lydston on athletics in genito-uri- 

nary diseases, 37 
Lymphadenitis gonorrhoeica, 80 
Lymphangitis, 81 

Malassez and Terrillon on epididy- 
mitis, 56 

Malodorous urine, 143 

Marital reinfection, 169 

Marriage of gonorrhceics, 208 

Massage of prostate, 183 

Masturbation, psychic, 170 

Masturbator's premature ejaculations, 
158 

Measuring size of prostate, 180 

Meatometer, Piffard's, 193 

Meatus, agglutination of, 136 ; exces- 
sive moisture at, 132 ; swollen, 4, 10 

Mechanism of gonorrhoeal infection, 8 
of symptomatology of posterior 
gonorrhoea, 21 

Megaloscope, 192 

Mercier curve catheters, 114 

Mercuric bichloride test, 206 ; in pos- 
terior gonorrhoea, 26 

Methylene blue in differentiation be- 
tween anterior and posterior gon- 
orrhoea, 25; stain for gonococci, 
208 

Michigan's law on the marriage of 
gonorrhceics, 211 

Microscope, preparing specimen for, 
207 

Milking urethra, 133 ; maintains ure- 
throrrhoea, 203 

Moisture, excessive, at meatus, 132 

Morgagnian crypts, 196, 200 

Morning drop, 137 

Muco-purulent filaments, 144 

Mucous filaments, 144 

Mucus, urethral, augmented early in 
gonorrhoea, 10 

Murcell on urethral rugosities, 150 

Neisser on the gonococcus, 209 
Neoplasms in the urethra, 166 



Nervous patients, irrigations of, 14 
Neuroses evoked by gonorrhoea, 26 ; 
by normal filament, 69 
gonorrhoeal, 82 ; in prostatitis, 
107 
Nitze-Oberlaender tubes, 190 
Noeggerath on gonorrhoea in women, 

208 
Nogu^s-Wassermann diplococcus, 123 
Normal filament, its discovery as a 

cause for neurasthenia, 69 
Nosophen in balanitis and balanopos- 
thitis, 43 ; in scrotal erosions from 
strapping, 63 
Nozzles for various sized meatus, 4 

mode of attachment, 5 
Nuclei of urethral epithelia thinned 
or absent in stricture, 66 

Oberlaender anterior dilator, 154 ; 
antero-posterior dilator, 159 ; B£- 
nique curve posterior dilator, 157 ; 
on carcinoma of the urethra, 200 ; 
on cavernitis, 46 ; on chronic ure- 
thritis, 126 ; on the treatment of 
chronic gonorrhoea, 146 ; on dilata- 
tions, 148; on "melting" infiltra- 
tions, 164 ; on splitting infiltrations, 
166 ; on psoriasis mucosae urethra- 
lis, 201 
Obstacles to dilatation, 154, 164 
Odor of urine changed by drugs, 143 
(Edema, artificial, induced by irriga- 
tions, 11 ; by gonorrhoea, 85 
Office arrangement, 33 
Orcho-epididymitis, 55 
Orgasm suppressed, 129 
Ophthalmia, gonorrhoeal, 85, 209 
Otis on catarrhal urethritis, 133 ; di- 

vulsor, 148 
Over-treatment, 84, 166 

Packing urethra to arrest bleeding, 
78, 164 

Pain after urination in posterior gon- 
orrhoea, 23, 24; connected with an 
attack of gonorrhoea, relieved by ir- 
rigations, 11 ; increased when local 



INDEX. 



219 



anaesthetics have worn off, 18 ; on 
urination after dilatations, pre- 
vented by irrigation, 161 

Painful erection, 82 

urination, 10 ; absent in gonor- 
rhoea, 11 

Painlessness of irrigations, 17 

Palpation of urethral adnexa, 173 

Paraphimosis, 86 

Patient, preparation of, for irriga- 
tions, 12 

Periarthritis, see Bheumatism 

Period of incubation, 9 

Peritonitis, gonorrhoea^ 76 

Peri-urethral abscess, 38 

Permanent catheterization, 112 

Phimosis, 88 

Phosphaturia, 144 

Physician's urethra infected from mi- 
croscopic specimen, 9 

Piffard meatometer, 193 

Ploss on ritual circumcision, 117 

Pollutions, 101 

Posner on condylomata, 50 ; on poste- 
rior gonorrhoea, 19 

Posterior gonorrhoea, acute, 19 ; 
avoided by irrigations, 20; causes 
of, 20 ; diagnosis of, 25 ; evoking 
neurosis, 26 ; fulminant type, treat- 
ment of, 27 ; presumed recovery 
without treatment, 21, 26 ; strength 
of irrigation solutions in, 26 ; symp- 
toms, 20 

Posterior irrigations, technique of, 
29; urethra, examination of, 196 

Postures in irrigation, 13 

Potassium permanganate, strength of 
solutions, 18 

Premature discontinuance of treat- 
ment, 167 ; ejaculations from mas- 
turbator's or other irritable poste- 
rior urethra, 139 

Premonitory symptoms of gonorrhoea, 
10 

Preparation of patient for irrigation, 
12 

Prepuce, adhesions of, 41, 88, 91 ; 
tight, irrigations of, 15 



Prevention of pregnancy, 129 

Prolongation of coitus, 129 

Proofs of cure of gonorrhoea, 202 

Prostate, massage of, 183 ; aided by 
fixing prostate with a sound, 183 

Prostatic examination by sound in the 
bladder and finger in the rectum, 
180 ; filaments, 69 

Prostatitis, acute, 102 ; chronic, 107 

Psoriasis mucosae urethralis (Ober- 
laender), 201 

Psychic masturbation, 170 

Psychrophor to arrest urethral bleed- 
ing, 164 

Purulent filaments, 144 

Pus in urine, caustic potash test for, 
11, 55, 144 

Pyuria, 11, 144 

Quiescent gonorrhoea, 168 

Ramonage, 205 

Rectal irrigations in prostatitis, 104 
Recumbent posture, irrigating in, 14 
"Recurrent " gonorrhoea, 168 
Relapse of acute symptoms from dila- 
tations avoided by irrigations, 161 
Relative sizes of bougies and dilators, 

163 
Residual gonorrhoea, 168 ; in women, 

184 
Retention catheter, 111 

of urine, 24, 108 
Rheumatism, gonorrhoeal, 114 
Rona on posterior gonorrhoea, 102, 115 
Rugosities on floor of urethra, 150 

Santal oil in posterior gonorrhoea, 27 

Sascke on urethral injuries from cir- 
cumcision, 118 

Schleich's infiltration in circumcis- 
ion, 92 ; in removal of inguinal 
glands, 81 

Scott on the dangers of gonorrhoea, 
127 

Scraping urethra, 205 

Scrotal erosions from strapping, 63 

Second urine turbid, not an infallible 
evidence of posterior urethritis, 25 



220 



INDEX. 



Semen, bloody or chocolate color, 102, 
122 ; ejaculation of, 132 ; premature 
emission of, 139 

Seminal dribbling after coitus, 139; 
emissions, 101 ; in posterior gonor- 
rhoea, 23 ; vesicles, examination of, 
182; stripping of, 183; vesiculitis, 
119 

Senn on tuberculosis of the genito- 
urinary organs, 56 

Sequelse of gonorrhoea, 38 

Sexual desire, excessive, 133 

Shield, cleansing of, 7 

Shreds in the urine, 144 

Simulated anterior gonorrhoea, 140 ; 
spermatorrhoea, 131 

Silver nitrate in posterior gonorrhoea, 
26 ; test, 206 

Skin diseases complicating or follow- 
ing gonorrhoea, 115 

Sounds, inefficient, 148 

Spermatic cord, inflammation of, 
73 

Spermatorrhoea, simulated, 131 

Staining for gonococci, 207 

Stains on linen, 131, 142 

Stammering urination (Guy on), 103 

Sterilization of dilator cover, 152 

Sternberg, smear preparation, 131 

Stewart, location of seminal vesicles, 
120 

Stone in urethra, 71 

Stopcock, author's, 4 

"Strain" producing gonorrhoea, 171 

Straining in posterior gonorrhoea, 24 

Strapping testicle, 61 

Stricture, evidenced by thinned ure- 
thral epithelium in urine, 66, 117 ; 
tight, 149 

Stripping seminal vesicles, 183 

Strong injections as a cause of poste- 
rior gonorrhoea, 20 

Suppositories in prostatitis, 105 

Suspensory bandages, 38 ; as a preven- 
tive of epididymitis, 57 

Swabbing urethra, 205 

Swinburne on irrigations, 1 

Symptoms of acute gonorrhoea, 10 



Syphilis, prevention of infection by 

nozzles, 8 
Syringe, Kollmann's capillary, for 

urethral glands, 165 

Tait on the frequency of gonorrhoea, 
208 

Tamponing urethra, 78, 164 

Taylor on extragenital infection, 9; 
on the frequency of posterior infec- 
tion, 19 ; on gonocystitis, 121 ; 
definition of phimosis, 88; phimo- 
sis scissors, 44 ; on skin diseases in 
gonorrhoea, 115; on slitting fore- 
skin, 44 

Technique of dilatations, 160 

Tenesmus in posterior gonorrhoea, 24 

Thummel on the impropriety of infect- 
ing a healthy urethra for purposes 
of investigation, 74 

Tickling in urethra, 135 

Tight foreskin, irrigations in, 15 
strictures, 149 

Time consumed in irrigations, 18 

Tobacco, 38 ; poultices in epididymi- 
tis, 65 

Traumatisms of the urethra, 117 

Treatment of chronic gonorrhoea, 145 

" Tripperfaden," 67 

" Trompeurs," 129 

Tuberculosis of the geni to-urinary or- 
gans, 56, 122 

Turbid urine, 11, 143 

Urethra, female, frequent site of re- 
sidual gonorrhoea, 8 
must not be washed with a cathe- 
ter, 20 ; traumatisms of, 117 
Urethral adnexa, palpation of, 173 
bleeding, control of, 164 
calculi, 71 
fever prevented by irrigations, 

12, 162 
fistula, 66 
glands, Kollmann's syringe for, 

165 
neoplasms, 166 
rugosities, 150 



INDEX, 



221 



Urethritis ab ingestis, 171 ; ex libi- 
dine, 170; irritative, from treat- 
ment of healthy urethra, 69 

Urethrocystitis, 53 

Urethroprostatic infection, 123 

Urethrorrhcea maintained by milking 
urethra, 131 

Urethroscope, author's, 190 

Urethroscopy, 188 ; technique of, 192 

Urethrospasm, avoided, 150 ; imped- 
ing dilatations, 103 

Urinal, Duchastelet, 112 

Urination drop, 129 

Urination, increased frequency early 
in gonorrhoea, 10 ; painful, 10, 11 ; 
painful at beginning, from incrus- 
tated meatus, 136 ; painful from local 
and constitutional disturbances, 139 

Urine, brought in bottles useless for 
examination of floaters, 70 ; urine, 
clear, 144 ; in chronic gonorrhoea, 
142 ; examination of, in posterior 
gonorrhoea, 25 ; of gonorrhoeic 
should be examined daily, 24 ; mal- 
odorous, 143; retention of, 11, 24 
108; scalding, 10, 11; tubes, 25; 
turbid, 11, 143 



Urotropin, 36 

Verhoogen on posterior urethritis, 

19 
Vesical tenesmus, 24 
Vesiculitis, 119 

Waiting for acute stage to pass off, a 

serious error, 11 
Wasiliew on ritual circumcision, 117 
Weichselbaum on condylomata, 48 
White and Martin on the early symp- 
toms of gonorrhoea, 10 ; on posterior 
urethritis, 20 ; on albuminuria in 
posterior urethritis, 22; on balani- 
tis, 42; rectal irrigator, 104; sus- 
pensory bandage, 64 
White wine, young, producing ure- 
thritis, 171 
Wife, danger of infecting from resid- 
ual gonorrhoea, 168 
Women, residual gonorrhoea in, 184 
Wossidlo on the need of rectal exam- 
ination, 20 ; on prostatitis, 102 ; on 
stricture, 116 

von Zeissl suspensory bandage, 64 



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PUBLICATIONS OF WILLIAM WOOD & COMPANY. 5 

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Coleman, Warren, M.D., 

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Collins, Joseph, M.D., 

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Delafield, Francis, M.D., 

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De Meric, H., Paris. 

DICTIONARY OF MEDICAL TERMS. (English-French.) This 
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Ellis, George Viner, fl.D., 

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Heitzmann, Louis, M.D. (New York). 

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PUBLICATIONS OF WILLIAM WOOD & COMPANY. 9 

Helferich, H., M.D., 

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AN ATLAS OF FRACTURES AND DISLOCATIONS. Translated 
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DIFFICULT LABOR : A Guide to its Management for Students and 
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Herrick, Clinton B., M.D., Troy, N. Y. 

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RAILWAY SURGERY. A handbook on the management of injuries. 
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Holden, Luther, n.D., 

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Household Practice. 

See WOOD'S HOUSEHOLD PRACTICE. 

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Hutchinson, Jonathan, F.R.S. 

THE PEDIGREE OF DISEASE. Being Six Lectures on Tempera- 
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Ingals, E. Fletcher, A.M., M.D., 

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Kellogg, Theodore H., A.M., H.D., 

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PUBLICATIONS OF WILLIAM WOOD & COMPANY. u 



Keyes, Edward L., M.D., 



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and Chetwood, Charles H., M.D., 

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Knies, Max, M.D., 

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Landau, Prof. Dr. Leopold, and 

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Ling, P. He. 

SYSTEM OF MANUAL TREATMENT AS APPLICABLE TO 
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Luff, Arthur P., M.D., B.Sc, F.R.C.P. Lond. 

GOUT; ITS PATHOLOGY AND TREATMENT. The subject of 
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Macfarlane, A. W., M.D., 

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Macnaughton= Jones, H., M.D., M.Ch. 

PRACTICAL MANUAL OF DISEASES OF WOMEN AND UTER- 
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Manson, Patrick, M.D., LL.D. Aberd. 

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May, Charles H., M.D., 

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PUBLICATIONS OF WILLIAM WOOD & COMPANY. 15 



Noman, Dr. D. Van Haren, 

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ESSAYS FOR STUDENTS. This little work is intended to illustrate 
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